Provider Demographics
NPI:1508196122
Name:SHAO, MICHAEL YUZHOU (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:YUZHOU
Last Name:SHAO
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 1:2740 W FOSTER AVE
Mailing Address - Street 2:STE LL7
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3543
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-293-4197
Practice Address - Street 1:5140 N CALIFORNIA AVE
Practice Address - Street 2:STE 780
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-989-3957
Practice Address - Fax:773-989-3971
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117153208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL406120OtherMEDICARE PTAN FOR SCMG
IL406120075OtherMEDICARE INDIVIDUAL PTAN
IL036117153Medicaid