Provider Demographics
NPI:1942457882
Name:SHEA, NICHOLAS JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:SHEA
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 1:2045 W GRAND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1577
Mailing Address - Country:US
Mailing Address - Phone:312-268-4070
Mailing Address - Fax:312-277-1042
Practice Address - Street 1:2045 W GRAND AVE STE B
Practice Address - Street 2:PMB 82557
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1577
Practice Address - Country:US
Practice Address - Phone:312-268-4070
Practice Address - Fax:312-277-1042
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361232632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123263Medicaid
IL206147OtherMEDICARE PTAN (GROUP)
IL206147027OtherMEDICARE PTAN (INDIVIDUAL)