Basic Information
| Provider Information | |||||||||
| NPI: | 1447555800 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEVINA SHAH SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11240 S MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606284941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734689000 | ||||||||
| FaxNumber: | 7739959181 | ||||||||
| Practice Location | |||||||||
| Address1: | 11240 S MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606284941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734689000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2011 | ||||||||
| LastUpdateDate: | 05/18/2011 | ||||||||
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| AuthorizedOfficialLastName: | SHAH | ||||||||
| AuthorizedOfficialFirstName: | DEVINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7737686200 | ||||||||
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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 | 207Q00000X | 036059687 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036059687 | 05 | IL | MEDICAID |