Provider Demographics
NPI:1518377324
Name:SHEFALI SHAH MD SC
Entity Type:Organization
Organization Name:SHEFALI SHAH MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEFALI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-348-9029
Mailing Address - Street 1:885 W LILL AVE
Mailing Address - Street 2:UNIT 4
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-6447
Mailing Address - Country:US
Mailing Address - Phone:773-348-9029
Mailing Address - Fax:
Practice Address - Street 1:2526 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2353
Practice Address - Country:US
Practice Address - Phone:773-929-7410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111947Medicaid
ILI45693Medicare UPIN
IL036111947Medicaid