Provider Demographics
NPI:1497067789
Name:SHAH, BANSARI (MD)
Entity Type:Individual
Prefix:
First Name:BANSARI
Middle Name:
Last Name:SHAH
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 1:253 E DELAWARE PL APT 4G
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1750
Mailing Address - Country:US
Mailing Address - Phone:562-477-1101
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-702-6757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125057860207P00000X
CAA125097207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine