=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366963332
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HANIT U SHAH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2017
-----------------------------------------------------
Last Update Date | 03/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27650 FERRY RD STE 110
-----------------------------------------------------
City | WARRENVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60555-3846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-315-6543
-----------------------------------------------------
Fax | 630-315-6537
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 MAIN ST STE A
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61602-1080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-672-4977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 036157704
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036157704
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------