=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508853979
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIPAK T SHAH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2005
-----------------------------------------------------
Last Update Date | 01/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5454 HOHMAN AVE
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46320-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-933-2270
-----------------------------------------------------
Fax | 219-852-2515
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2009 MIDWEST CLUB PKWY
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-2526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-272-7950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 01055335A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------