Provider Demographics
NPI:1891862959
Name:SHAH, KUMUDCHANDRA S (MD)
Entity Type:Individual
Prefix:MR
First Name:KUMUDCHANDRA
Middle Name:S
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KUMUD
Other - Middle Name:S
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:17680 S KEDZIE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2043
Mailing Address - Country:US
Mailing Address - Phone:708-799-5420
Mailing Address - Fax:708-799-4093
Practice Address - Street 1:17680 S KEDZIE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2043
Practice Address - Country:US
Practice Address - Phone:708-799-5420
Practice Address - Fax:708-799-4093
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048096207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048096Medicaid
IL21605584OtherBLUE CROSS BLUE SHIELD
IL470830Medicare ID - Type Unspecified
IL21605584OtherBLUE CROSS BLUE SHIELD