Provider Demographics
NPI:1356331961
Name:SHORTAL, BRIAN PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PATRICK
Last Name:SHORTAL
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 1:2151 WAUKEGAN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1885
Mailing Address - Country:US
Mailing Address - Phone:847-444-5328
Mailing Address - Fax:847-267-0694
Practice Address - Street 1:2151 WAUKEGAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1885
Practice Address - Country:US
Practice Address - Phone:847-444-5328
Practice Address - Fax:847-267-0694
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-111585207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04915267OtherBLUE CROSS BLUE SHIELD
IL36111585Medicaid
IL234170Medicare PIN
IL36111585Medicaid
ILK38146Medicare PIN
IL777210Medicare PIN
ILI73683Medicare UPIN
ILK38145Medicare PIN