Basic Information
Provider Information | |||||||||
NPI: | 1972730893 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAH | ||||||||
FirstName: | MIHIR | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1221 N HIGHLAND AVE | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | IL | ||||||||
PostalCode: | 605061404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6309073969 | ||||||||
FaxNumber: | 6309073998 | ||||||||
Practice Location | |||||||||
Address1: | 1221 N HIGHLAND AVE | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | IL | ||||||||
PostalCode: | 605061404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6309073969 | ||||||||
FaxNumber: | 6309073998 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2009 | ||||||||
LastUpdateDate: | 10/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Q4281 | TX | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 036140889 | IL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 407299YSHD | 01 | TX | STRIC - MEDICARE | OTHER | P01473738 | 01 | TX | STRIC - RR MEDICARE | OTHER | 3462442-02 | 01 | TX | STRG - MEDICAID | OTHER | P01473741 | 01 | TX | STRG - RR MEDICARE | OTHER | 3462442-03 | 01 | TX | STRG - MEDICAID - CSHCN | OTHER | 407299YSHE | 01 | TX | STRG - MEDICARE | OTHER | 3462442-01 | 01 | TX | STRIC - MEDICAID | OTHER | Q4281 | 01 | TX | TEXAS MEDICAL LICENSE | OTHER |