Healthcare Provider Details

I. General information

NPI: 1316935240
Provider Name (Legal Business Name): PRABODH C SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 W 95TH ST CANCER CENTER
EVERGREEN PARK IL
60805-2701
US

IV. Provider business mailing address

2800 W 95TH ST CANCER CENTER
EVERGREEN PARK IL
60805-2701
US

V. Phone/Fax

Practice location:
  • Phone: 708-229-6020
  • Fax: 708-229-6083
Mailing address:
  • Phone: 708-229-6020
  • Fax: 708-229-6083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036042091
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA25747
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: