Basic Information
| Provider Information | |||||||||
| NPI: | 1083809081 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | MAHESH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1021 COURT ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615544802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096426705 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20201 CRAWFORD AVE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086792160 | ||||||||
| FaxNumber: | 7086792161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2007 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036135679 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 4301097605 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 208M00000X | 036135679 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.