Provider Demographics
NPI:1629024815
Name:SHAH, PANKAJ S (MD)
Entity Type:Individual
Prefix:DR
First Name:PANKAJ
Middle Name:S
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 1:10035 LINCOLN TRL
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-1847
Mailing Address - Country:US
Mailing Address - Phone:618-397-7700
Mailing Address - Fax:618-397-7735
Practice Address - Street 1:10035 LINCOLN TRL
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-1847
Practice Address - Country:US
Practice Address - Phone:618-397-7700
Practice Address - Fax:618-397-7735
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD13159Medicare UPIN
ILK37711Medicare PIN
IL493181Medicare ID - Type Unspecified