Provider Demographics
NPI:1083710263
Name:SHIRLEY A ROY, MDSC
Entity Type:Organization
Organization Name:SHIRLEY A ROY, MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-878-5151
Mailing Address - Street 1:5419 N SHERIDAN RD
Mailing Address - Street 2:106
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1964
Mailing Address - Country:US
Mailing Address - Phone:773-878-5151
Mailing Address - Fax:773-878-1134
Practice Address - Street 1:5419 N SHERIDAN RD
Practice Address - Street 2:106
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1964
Practice Address - Country:US
Practice Address - Phone:773-878-5151
Practice Address - Fax:773-878-1134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3645111207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36045111Medicaid
IL213235Medicare ID - Type Unspecified
ILD12507Medicare UPIN