Provider Demographics
NPI:1083809081
Name:SHAH, NICHOLAS MAHESH (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MAHESH
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 1:1021 COURT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-4802
Mailing Address - Country:US
Mailing Address - Phone:309-642-6705
Mailing Address - Fax:
Practice Address - Street 1:20201 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1010
Practice Address - Country:US
Practice Address - Phone:708-679-2160
Practice Address - Fax:708-679-2161
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036135679207RN0300X, 208M00000X
MI4301097605207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology