Healthcare Provider Details

I. General information

NPI: 1184636805
Provider Name (Legal Business Name): SHAKU CHHABRIA NEUROLOGICAL SERVICES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S GREENLEAF ST STE 111
GURNEE IL
60031-5705
US

IV. Provider business mailing address

222 S GREENLEAF ST STE 111
GURNEE IL
60031-5705
US

V. Phone/Fax

Practice location:
  • Phone: 847-360-0044
  • Fax: 847-360-8804
Mailing address:
  • Phone: 847-360-0044
  • Fax: 847-360-8804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036053149
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number036053149
License Number StateIL

VIII. Authorized Official

Name: SHAKUNTALA CHHABRIA
Title or Position: OWNER
Credential: MD
Phone: 847-360-0044