Healthcare Provider Details

I. General information

NPI: 1972073286
Provider Name (Legal Business Name): ROSHNI SHAH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 04/11/2025
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 ELISHA AVENUE
ZION IL
60099
US

IV. Provider business mailing address

2361 PAYSPHERE CIRCLE
CHICAGO IL
60067
US

V. Phone/Fax

Practice location:
  • Phone: 800-322-9183
  • Fax:
Mailing address:
  • Phone: 800-322-9183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA8246
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006840
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number085-006840
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: