Provider Demographics
NPI:1740236835
Name:SHANES, JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:SHANES
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 1:675 W NORTH AVE
Mailing Address - Street 2:SUITE-210
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1634
Mailing Address - Country:US
Mailing Address - Phone:708-838-1448
Mailing Address - Fax:708-344-0508
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE-210
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-838-1448
Practice Address - Fax:708-344-0508
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-064782174400000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110032830OtherRAILROAD MEDICARE INDIVIDUAL PROVIDER ID NUMBER
IL216577OtherMEDICARE GROUP PTAN FOR LOCALITY 015
IL1164530713OtherGROUP NPI NUMBER FOR CONSULTANTS IN CARDIOVASCULAR MEDICINE S C
IL31602469OtherBLUECROSS BLUE SHIELD GROUP PROVIDER NUMBER
IL036-064782Medicaid
ILK51366OtherMEDICARE INDIVIDUAL PTAN FOR LOALITY 015
IL209712OtherMEDICARE GROUP NUMBER
IL961280OtherMEDICARE GROUP NUMBER FOR CONSULTANTS IN CARDIOVASCULAR MEDICINE, S.C.
ILL18915OtherMEDICARE PTAN NUMBER
ILCC1592OtherRAILROAD MEDICARE GROUP PTAN NUMBER
IL216577OtherMEDICARE GROUP PTAN FOR LOCALITY 015