Provider Demographics
NPI:1467647099
Name:VIBHAKAR S SHAH M.D., S.C.
Entity Type:Organization
Organization Name:VIBHAKAR S SHAH M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIBHAKAR
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-249-0167
Mailing Address - Street 1:222 S GREENLEAF ST
Mailing Address - Street 2:SUITE #109
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5705
Mailing Address - Country:US
Mailing Address - Phone:847-249-0167
Mailing Address - Fax:847-249-0717
Practice Address - Street 1:222 S GREENLEAF ST
Practice Address - Street 2:SUITE #109
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5705
Practice Address - Country:US
Practice Address - Phone:847-249-0167
Practice Address - Fax:847-249-0717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212750Medicare PIN