Basic Information
| Provider Information | |||||||||
| NPI: | 1477561744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | ASHVIN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2315 E 93RD ST STE 340 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606173948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734689000 | ||||||||
| FaxNumber: | 8475876113 | ||||||||
| Practice Location | |||||||||
| Address1: | 2315 E 93RD ST STE 340 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606173948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734689000 | ||||||||
| FaxNumber: | 8475876113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 11/17/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036058180 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036058180 | 05 | IL | MEDICAID |