Healthcare Provider Details

I. General information

NPI: 1457709404
Provider Name (Legal Business Name): SHAWN KOTHARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

180 HARVESTER DR SUITE 110
BURR RIDGE IL
60527-7594
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-6840
  • Fax: 773-702-2230
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125068590
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number91582
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036169066
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: