Provider Demographics
NPI:1578561767
Name:TANNA, SHITAL (MD)
Entity Type:Individual
Prefix:DR
First Name:SHITAL
Middle Name:
Last Name:TANNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:1710 N RANDALL ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4717
Practice Address - Country:US
Practice Address - Phone:847-214-5770
Practice Address - Fax:847-214-5777
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094105Medicaid
IL347923353OtherTRICARE
ILP00114561OtherRAILROAD MEDICARE
IL610033301OtherDOL WORKCOMP
IL04532170OtherBLUE CROSS BLUE SHIELD
ILDB0387OtherRAILROAD MEDICARE GROUP
ILK04338Medicare ID - Type UnspecifiedLOCALITY 15
ILP00114561OtherRAILROAD MEDICARE
IL04532170OtherBLUE CROSS BLUE SHIELD