Provider Demographics
NPI:1659412682
Name:SHAH, HASSAN
Entity Type:Individual
Prefix:
First Name:HASSAN
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 HARVESTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:888-824-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-11
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123095207WX0200X, 207W00000X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123095Medicaid
IL6180260001OtherDEMERC SUPPLIER PTAN
IL1699802421OtherOPTICAL NPI
IN12100239OtherCAQH 12100239
IL205785OtherILLINOIS MEDICARE PTAN COOK COUNTY FOR GROUP
IL12100239OtherCAQH 12100239
IN200871680COtherINDIANA MEDICAID LOCATION ORLAND PARK C
IN530943OtherANTHEM BC/ BS
ILCK7818OtherMEDICARE RAILROAD GRP PTAN
IN200871680AOtherINDIANA MEDICAID MUNSTER LOCATION A
IL1700191012OtherUNIVERSITY OF CHICAGO MEDICAL CENTER NPI
IN200945500OtherLEGACY PROVIDER IDENTIFIER (LPI) 200945500
IL205786OtherILLINOIS MEDICARE PTAN DUPAGE COUNTY FOR GROUP
IN200871680BOtherINDIANA MEDICAID LOCATION CHICAGO RIDGE B
IL01620861OtherBLUE CROSS AND BLUE SHIELD
IN200871680DOtherINDIANA MEDICAID LOCATION HINSDALE D
IN253350OtherPTAN INDIANA MEDICARE GROUP
IN530943OtherANTHEM BC/ BS