Basic Information
| Provider Information | |||||||||
| NPI: | 1184636805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHAKU CHHABRIA NEUROLOGICAL SERVICES SC | ||||||||
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| OtherOrganizationName: | CHHABRIA NEUROLOGICAL SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 S GREENLEAF ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600315705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473600044 | ||||||||
| FaxNumber: | 8473608804 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 S GREENLEAF ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600315705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473600044 | ||||||||
| FaxNumber: | 8473608804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | CHHABRIA | ||||||||
| AuthorizedOfficialFirstName: | SHAKUNTALA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8473600044 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | 036053149 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0400X | 036053149 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | DE1546 | 01 | IL | RAIL ROAD MEDICARE | OTHER | 036053149 | 05 | IL | MEDICAID | 4900918 | 01 | IL | BLUE CROSS/SHIELD | OTHER |