Provider Demographics
NPI:1891890430
Name:ALSAFWAH, SHADWAN F (MD)
Entity Type:Individual
Prefix:DR
First Name:SHADWAN
Middle Name:F
Last Name:ALSAFWAH
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 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:901-302-2360
Practice Address - Street 1:17850 KEDZIE AVE STE 3250
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2082
Practice Address - Country:US
Practice Address - Phone:708-799-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39235207RC0000X, 207RI0011X
AZ41527207RC0000X
IL036-098886207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3337932Medicaid
AZ425003Medicaid
TN103I062027OtherMEDICARE
H01545Medicare UPIN
AZ425003Medicaid