Provider Demographics
NPI:1861643801
Name:SHAH, CHIRAG M (MD)
Entity Type:Individual
Prefix:
First Name:CHIRAG
Middle Name:M
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 1:1725 W HARRISON ST STE 118
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3835
Mailing Address - Country:US
Mailing Address - Phone:312-942-8905
Mailing Address - Fax:312-942-2384
Practice Address - Street 1:1725 W HARRISON ST STE 118
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3835
Practice Address - Country:US
Practice Address - Phone:312-942-8905
Practice Address - Fax:312-942-2384
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117834208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117834OtherSTATE LICENSE