MEDICARE: CHARLES T SHAW M.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	207R00000X	Internal Medicine Physician	036078790	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720086960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES T SHAW M.D.

Provider Business Mailing Address
First Line	:	6084 S ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-2747
Country	:	US
Telephone Number	:	773-355-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	6084 S ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-2747
Country	:	US
Telephone Number	:	773-355-2800
Fax Number	:

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

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	03/04/2024

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