MEDICARE: INDIRA SHAH

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	207Q00000X	Family Medicine Physician	36057975	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	110008973	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31600190	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1881600187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	INDIRA SHAH

Provider Business Mailing Address
First Line	:	75 REMITTANCE DR DEPT 1704
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60675-1704
Country	:	US
Telephone Number	:	727-823-2188
Fax Number	:

Provider Business Practice Location Address
First Line	:	2526 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2353
Country	:	US
Telephone Number	:	773-929-7410
Fax Number	:

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	09/25/2012

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Directions to “ INDIRA SHAH ” Practice Location

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