Healthcare Provider Details

I. General information

NPI: 1265792212
Provider Name (Legal Business Name): SONIA SHAH M D S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 05/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 N CICERO AVE SUITE 203
CHICAGO IL
60641-1651
US

IV. Provider business mailing address

4211 N CICERO AVE SUITE 203
CHICAGO IL
60641-1651
US

V. Phone/Fax

Practice location:
  • Phone: 773-794-8800
  • Fax:
Mailing address:
  • Phone: 773-794-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number036121040
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036121040
License Number StateIL

VIII. Authorized Official

Name: DR. SONIA SHAH
Title or Position: PRESIDENT
Credential:
Phone: 773-794-8800