Provider Demographics
NPI:1073606323
Name:NYI, SHAI
Entity Type:Individual
Prefix:
First Name:SHAI
Middle Name:
Last Name:NYI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9774
Mailing Address - Country:US
Mailing Address - Phone:815-844-6551
Mailing Address - Fax:309-842-1793
Practice Address - Street 1:2500 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9774
Practice Address - Country:US
Practice Address - Phone:815-844-6551
Practice Address - Fax:309-842-1793
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085947207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2613OtherMEDICARE GROUP PTAN
P00823122OtherRR INDIVIDUAL # COLLEGE AVE
IL036085947Medicaid
DP5951OtherRR GROUP # COLLEGE AVE
ILCA2182Medicare ID - Type UnspecifiedRR GROUP #
IL833250Medicare ID - Type UnspecifiedGROUP #
ILL52425Medicare ID - Type UnspecifiedINDIVIDUAL
ILIL2613042Medicare PIN
DP5951OtherRR GROUP # COLLEGE AVE
IL036085947Medicaid