MEDICARE: VICKI M SHAH PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1457502478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKI M SHAH PA

Provider Business Mailing Address
First Line	:	1725 W HARRISON ST STE 319
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3852
Country	:	US
Telephone Number	:	312-942-8910
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 W HARRISON ST STE 319
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3852
Country	:	US
Telephone Number	:	312-942-8910
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2008
Last Update Date	:	01/07/2016

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Directions to “ VICKI M SHAH PA” Practice Location

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