Healthcare Provider Details

I. General information

NPI: 1679093413
Provider Name (Legal Business Name): MANSI R SHAH MD, MBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 WEST HARRISON STREET
CHICAGO IL
60612
US

IV. Provider business mailing address

4720 N CLARENDON AVE
CHICAGO IL
60640-5122
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5000
  • Fax:
Mailing address:
  • Phone: 773-977-4031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036159871
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036159871
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: