Healthcare Provider Details

I. General information

NPI: 1215030689
Provider Name (Legal Business Name): RESHMA SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST STE 2E
CHICAGO IL
60612-4795
US

IV. Provider business mailing address

840 S WOOD ST # MC856
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7416
  • Fax: 312-413-8778
Mailing address:
  • Phone: 312-355-1675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036116066
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: