Provider Demographics
NPI:1003920547
Name:SHAH, MANOJ (MD)
Entity Type:Individual
Prefix:DR
First Name:MANOJ
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 DEMPSTER ST
Mailing Address - Street 2:SUITE 280
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1186
Mailing Address - Country:US
Mailing Address - Phone:847-318-9071
Mailing Address - Fax:847-318-2535
Practice Address - Street 1:1875 DEMPSTER ST
Practice Address - Street 2:SUITE 280
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1186
Practice Address - Country:US
Practice Address - Phone:847-318-9071
Practice Address - Fax:847-318-2535
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360687942086S0102X, 2086S0127X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068794Medicaid
ILC44404Medicare UPIN