Basic Information
| Provider Information | |||||||||
| NPI: | 1457698748 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHAH ALAM PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1057 CHERRY LN | ||||||||
| Address2: | |||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601484033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303067944 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2701 W 68TH ST | ||||||||
| Address2: | HOLY CROSS HOSPITAL | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606291813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738849000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2013 | ||||||||
| LastUpdateDate: | 01/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | ALAM | ||||||||
| AuthorizedOfficialFirstName: | SHAH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6303067944 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036114268 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 036114268 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036114268 | 05 | IL | MEDICAID |