Healthcare Provider Details

I. General information

NPI: 1558452474
Provider Name (Legal Business Name): SHAHID A ANSARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 EAST 51ST STREET
CHICAGO IL
60615
US

IV. Provider business mailing address

819 REDSTABLEWAY
OAKBROOK IL
60523
US

V. Phone/Fax

Practice location:
  • Phone: 312-572-2664
  • Fax: 312-572-2681
Mailing address:
  • Phone: 630-794-0527
  • Fax: 630-794-0547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number36-49188
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: