Provider Demographics
NPI:1700996568
Name:BAJAJ, RENU (MD)
Entity Type:Individual
Prefix:DR
First Name:RENU
Middle Name:
Last Name:BAJAJ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2413
Mailing Address - Country:US
Mailing Address - Phone:217-345-3909
Mailing Address - Fax:217-345-3007
Practice Address - Street 1:901 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2413
Practice Address - Country:US
Practice Address - Phone:217-345-3909
Practice Address - Fax:217-345-3007
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053197Medicaid
ILB02981Medicare UPIN
IL692760Medicare PIN