Healthcare Provider Details

I. General information

NPI: 1023498029
Provider Name (Legal Business Name): SHREYA KANABAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 W JACKSON BLVD
CHICAGO IL
60612-3276
US

IV. Provider business mailing address

1650 W HARRISON ST SUITE 466 ATRIUM
CHICAGO IL
60612-3800
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125067156
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: