Healthcare Provider Details

I. General information

NPI: 1003920547
Provider Name (Legal Business Name): MANOJ SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST SUITE 280
PARK RIDGE IL
60068-1186
US

IV. Provider business mailing address

1875 DEMPSTER ST SUITE 280
PARK RIDGE IL
60068-1186
US

V. Phone/Fax

Practice location:
  • Phone: 847-318-9071
  • Fax: 847-318-2535
Mailing address:
  • Phone: 847-318-9071
  • Fax: 847-318-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036068794
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number036068794
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number036068794
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: