Healthcare Provider Details

I. General information

NPI: 1811713985
Provider Name (Legal Business Name): SHUN TANAKA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S. MARYLAND AVE. M/C 5040
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-2500
  • Fax:
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number125087103
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: