Healthcare Provider Details

I. General information

NPI: 1396822086
Provider Name (Legal Business Name): SHOBHA SHAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 W ROOSEVELT RD 1231 W ROOSEVELT RD
CHICAGO IL
60608-1413
US

IV. Provider business mailing address

1231 W ROOSEVELT RD 1231 W ROOSEVELT RD
CHICAGO IL
60608-1413
US

V. Phone/Fax

Practice location:
  • Phone: 312-733-2555
  • Fax: 312-733-2555
Mailing address:
  • Phone: 312-733-2555
  • Fax: 312-733-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: