Provider Demographics
NPI:1558452474
Name:ANSARI, SHAHID A (MD)
Entity Type:Individual
Prefix:
First Name:SHAHID
Middle Name:A
Last Name:ANSARI
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 1:819 REDSTABLEWAY
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523
Mailing Address - Country:US
Mailing Address - Phone:630-794-0527
Mailing Address - Fax:630-794-0547
Practice Address - Street 1:500 EAST 51ST STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615
Practice Address - Country:US
Practice Address - Phone:312-572-2664
Practice Address - Fax:312-572-2681
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-49188208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL487180Medicare ID - Type Unspecified
ILD 12990Medicare UPIN