Basic Information
| Provider Information | |||||||||
| NPI: | 1245487008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHALISE | ||||||||
| FirstName: | SHYAM | ||||||||
| MiddleName: | |||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 N LAKE SHORE DR | ||||||||
| Address2: | LABOURE CLINIC SJH | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736653080 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2900 N LAKE SHORE DR | ||||||||
| Address2: | LABOURE CLINIC SJH | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736653080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2008 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125053919 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.