MEDICARE: SHIFA MEDICAL LAB LLC

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1215697651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHIFA MEDICAL LAB LLC

Provider Business Mailing Address
First Line	:	PO BOX 597315
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-7315
Country	:	US
Telephone Number	:	630-674-1974
Fax Number	:	773-583-6301

Provider Business Practice Location Address
First Line	:	5797 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4722
Country	:	US
Telephone Number	:	630-674-1974
Fax Number	:	773-583-6301

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MAZHER M SHAH-KHAN
Credential	:
Telephone Number	:	630-674-1974

Provider Enumeration Date	:	12/27/2021
Last Update Date	:	12/27/2021

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