Provider Demographics
NPI:1326579103
Name:SHAH, RAVI
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:
Last Name:SHAH
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 1:7543 183RD ST
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6208
Mailing Address - Country:US
Mailing Address - Phone:708-263-2000
Mailing Address - Fax:708-263-2023
Practice Address - Street 1:7543 183RD ST
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6208
Practice Address - Country:US
Practice Address - Phone:708-263-2000
Practice Address - Fax:708-263-2023
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.149951207QS0010X
IL125.070237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1326579103Medicaid