Provider Demographics
NPI:1497851703
Name:YATIN M SHAH MD SC
Entity Type:Organization
Organization Name:YATIN M SHAH MD SC
Other - Org Name:PRIMARY CARE JOLIET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MITI
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-726-2200
Mailing Address - Street 1:2025 S CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60436-3172
Mailing Address - Country:US
Mailing Address - Phone:815-726-2200
Mailing Address - Fax:815-727-1442
Practice Address - Street 1:2025 S CHICAGO ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60436-3172
Practice Address - Country:US
Practice Address - Phone:815-726-2200
Practice Address - Fax:815-727-1442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209006800OtherAPN LICENSE