Healthcare Provider Details

I. General information

NPI: 1518931906
Provider Name (Legal Business Name): SUBHASH K SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11413 BURR OAK LN
BURR RIDGE IL
60527-8008
US

IV. Provider business mailing address

PO BOX 206
WILLOW SPRINGS IL
60480-0206
US

V. Phone/Fax

Practice location:
  • Phone: 312-567-5560
  • Fax: 773-337-9106
Mailing address:
  • Phone: 312-567-5560
  • Fax: 773-337-9106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number036051531
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036051531
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: