Healthcare Provider Details

I. General information

NPI: 1861649451
Provider Name (Legal Business Name): RICKY SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RICKY BHARAT SHAH

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01072947A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number01072947A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036119458
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: