Provider Demographics
NPI:1871041244
Name:SHAH, EJAZ
Entity Type:Individual
Prefix:
First Name:EJAZ
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 1:800 E CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036149641208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist