MEDICARE: MRS. CHANDRIKA SHAH PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	085-001953	IL
2	363AS0400X	Surgical Physician Assistant	MS0930241	IL

General Provider Information

NPI Number	:	1114928884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHANDRIKA SHAH PA

Provider Business Mailing Address
First Line	:	500 E 51ST ST
Second Line	:	PROVIDENT HOSPITAL OF COOK COUNTY, DEPT OF SURGERY
City	:	CHICAGO
State	:	IL
Zip	:	60615-2400
Country	:	US
Telephone Number	:	312-572-2664
Fax Number	:	312-572-2681

Provider Business Practice Location Address
First Line	:	500 E 51ST STREET
Second Line	:	PROVIDENT HOSPITAL OF COOK COUNTY DEPT OF GEN SURGERY
City	:	CHICAGO
State	:	IL
Zip	:	60615
Country	:	US
Telephone Number	:	312-572-2664
Fax Number	:	312-572-2681

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	04/30/2021

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