Provider Demographics
NPI:1518040617
Name:SHAH, SURESH (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:SHAH
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 1:88 SILO RIDGE RD W
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-7331
Mailing Address - Country:US
Mailing Address - Phone:708-460-8605
Mailing Address - Fax:
Practice Address - Street 1:8012 S CRANDON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1124
Practice Address - Country:US
Practice Address - Phone:773-356-5415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-064403207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C51058Medicare UPIN
IL692620Medicare PIN