Provider Demographics
NPI:1003052655
Name:SHAW, SHIRLEY ANN
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANN
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17851 GLADVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-1836
Mailing Address - Country:US
Mailing Address - Phone:773-386-5355
Mailing Address - Fax:708-991-7835
Practice Address - Street 1:17851 GLADVILLE AVE
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1836
Practice Address - Country:US
Practice Address - Phone:773-386-5355
Practice Address - Fax:708-991-7835
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-04
Last Update Date:2009-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILMC6805343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)