Basic Information
| Provider Information | |||||||||
| NPI: | 1891890430 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALSAFWAH | ||||||||
| FirstName: | SHADWAN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29373 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473905900 | ||||||||
| FaxNumber: | 9013022360 | ||||||||
| Practice Location | |||||||||
| Address1: | 17850 KEDZIE AVE STE 3250 | ||||||||
| Address2: | |||||||||
| City: | HAZEL CREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604292082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087998700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 39235 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 41527 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 39235 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 036-098886 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 3337932 | 05 | TN | MEDICAID | 425003 | 05 | AZ | MEDICAID | 103I062027 | 01 | TN | MEDICARE | OTHER |