Basic Information
| Provider Information | |||||||||
| NPI: | 1578561767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TANNA | ||||||||
| FirstName: | SHITAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 29373 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473905900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1710 N RANDALL ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472145770 | ||||||||
| FaxNumber: | 8472145777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036094105 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036094105 | 05 | IL | MEDICAID | 347923353 | 01 | IL | TRICARE | OTHER | P00114561 | 01 | IL | RAILROAD MEDICARE | OTHER | 610033301 | 01 | IL | DOL WORKCOMP | OTHER | 04532170 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | DB0387 | 01 | IL | RAILROAD MEDICARE GROUP | OTHER |