Provider Demographics
NPI:1821403569
Name:SHANES, ELISHEVA DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:ELISHEVA
Middle Name:DOUGLAS
Last Name:SHANES
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 1:710 N FAIRBANKS CT STE 2-461
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3013
Mailing Address - Country:US
Mailing Address - Phone:312-926-3212
Mailing Address - Fax:
Practice Address - Street 1:710 N FAIRBANKS CT STE 2-461
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-926-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036146153207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology