Basic Information
| Provider Information | |||||||||
| NPI: | 1669649158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NHO | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WESTBROOK CORPORATE CTR | ||||||||
| Address2: | #240 | ||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601545701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082362673 | ||||||||
| FaxNumber: | 7084925673 | ||||||||
| Practice Location | |||||||||
| Address1: | 1611 W HARRISON ST | ||||||||
| Address2: | STE 400 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122434244 | ||||||||
| FaxNumber: | 3129421517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2008 | ||||||||
| LastUpdateDate: | 09/12/2011 | ||||||||
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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 | 207XX0005X | 036-120601 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | # 1633878 | 01 | IL | BCBS | OTHER |