MEDICARE: HARENDRA P. SHAH PA-C

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	363AM0700X	Medical Physician Assistant	085-001700	IL

General Provider Information

NPI Number	:	1306847207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HARENDRA P. SHAH PA-C

Provider Business Mailing Address
First Line	:	6349, N FAIRFIELD AVENUE
Second Line	:	PRISM MEDICAL CENTER
City	:	CHICAGO
State	:	IL
Zip	:	60659-1705
Country	:	US
Telephone Number	:	773-262-1300
Fax Number	:	773-262-1184

Provider Business Practice Location Address
First Line	:	6349, N FAIRFIELD AVENUE
Second Line	:	PRISM MEDICAL CENTER
City	:	CHICAGO
State	:	IL
Zip	:	60659-1705
Country	:	US
Telephone Number	:	773-262-1300
Fax Number	:	773-262-1184

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	10/25/2024

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