Provider Demographics
NPI:1649566407
Name:MISBAH, SHAHEEN FATIMA (MD)
Entity Type:Individual
Prefix:
First Name:SHAHEEN
Middle Name:FATIMA
Last Name:MISBAH
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 1:1015 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-4362
Mailing Address - Country:US
Mailing Address - Phone:847-289-8355
Mailing Address - Fax:
Practice Address - Street 1:1015 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120
Practice Address - Country:US
Practice Address - Phone:847-289-8355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036133955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036133955Medicaid