Healthcare Provider Details

I. General information

NPI: 1083710263
Provider Name (Legal Business Name): SHIRLEY A ROY, MDSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5419 N SHERIDAN RD 106
CHICAGO IL
60640-1964
US

IV. Provider business mailing address

5419 N SHERIDAN RD 106
CHICAGO IL
60640-1964
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-5151
  • Fax: 773-878-1134
Mailing address:
  • Phone: 773-878-5151
  • Fax: 773-878-1134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number3645111
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number3645111
License Number StateIL

VIII. Authorized Official

Name: DR. SHIRLEY A ROY
Title or Position: PRESIDENT
Credential: MD
Phone: 773-878-5151