Healthcare Provider Details

I. General information

NPI: 1093165128
Provider Name (Legal Business Name): SHAMA SHIRAZI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 06/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MCHENRY RD
WHEELING IL
60090
US

IV. Provider business mailing address

370 SUMMIT ST
ELGIN IL
60120-3843
US

V. Phone/Fax

Practice location:
  • Phone: 847-608-1344
  • Fax:
Mailing address:
  • Phone: 847-608-6345
  • Fax: 847-888-0835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.149649
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: