Provider Demographics
NPI:1457500787
Name:TIEN, SHELLY H (MD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:H
Last Name:TIEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 MAPLE AVE
Mailing Address - Street 2:APARTMENT 1105E
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:STE. 1420
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-570-2860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55482207V00000X
IL036.128275207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology