Healthcare Provider Details

I. General information

NPI: 1962430272
Provider Name (Legal Business Name): MAYANK KANAIYALAL SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7435 W TALCOTT AVE SUITE 182
CHICAGO IL
60631-3707
US

IV. Provider business mailing address

7435 W TALCOTT AVE SUITE 182
CHICAGO IL
60631-3707
US

V. Phone/Fax

Practice location:
  • Phone: 773-792-5154
  • Fax: 773-594-7975
Mailing address:
  • Phone: 773-792-5154
  • Fax: 773-594-7975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036106149
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number036106149
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: