MEDICARE: BIRVA K SHAH O.D.

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	152W00000X	Optometrist	046010543	IL
2	152WP0200X	Pediatric Optometrist	046010543	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	CK7818	OTHER	IL	RAILROAD MEDICARE ESC GROUP# CK7818
10	502720062	OTHER	IL	MEDICARE PTAN
12	253350	OTHER	IN	INDIANA MEDICARE GROUP PTAN 253350
13	253350	OTHER	IL	ILLINOIS MEDICARE GROUP PTAN 253350

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01621679	OTHER	IL	BLUE CROSS & BLUE SHEILD ESC # 01621679
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1083684922	OTHER	IN	THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1083684922
5	1700191012	OTHER	IL	UNIVERSITY OF CHICAGO MEDICAL CENTER NPI
7	1083684922	OTHER	IL	THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1083684922
8	12385422	OTHER	IL	CAQH
9	1699802421	OTHER	IL	OPTICAL THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1699802421
11	14D2054175	OTHER	IL	CLIA # 14D2054175 EXP 2-14-2015 CHICAGO RIDGE LOCATION
14	6180260001	OTHER	IL	DEMERC SUPPLIER PTAN 6180260001 THE EYE SPECIALISTS CENTER, LLC

General Provider Information

NPI Number	:	1134481211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BIRVA K SHAH O.D.

Provider Business Mailing Address
First Line	:	4684 DEPT
Second Line	:
City	:	CAROL STREAM
State	:	IL
Zip	:	60122-4684
Country	:	US
Telephone Number	:	708-423-4192
Fax Number	:	708-952-0329

Provider Business Practice Location Address
First Line	:	10436 SOUTHWEST HWY
Second Line	:	SUITE 101
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-2282
Country	:	US
Telephone Number	:	708-423-4192
Fax Number	:	708-952-0329

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

Provider Enumeration Date	:	06/13/2012
Last Update Date	:	10/18/2013

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Directions to “ BIRVA K SHAH O.D.” Practice Location

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