Healthcare Provider Details

I. General information

NPI: 1467473231
Provider Name (Legal Business Name): PRAVIN S SHAH M.D,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400E GOLF RD 222
DES PLAINES IL
60016-1252
US

IV. Provider business mailing address

1400E GOLF RD 222
DES PLAINES IL
60016-1252
US

V. Phone/Fax

Practice location:
  • Phone: 847-391-6360
  • Fax: 847-391-6360
Mailing address:
  • Phone: 847-391-6360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036055437
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036055437
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: