Provider Demographics
NPI:1972542611
Name:SHAH, SHIRISH N (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIRISH
Middle Name:N
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 1:1146 PARK
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305
Mailing Address - Country:US
Mailing Address - Phone:773-283-2448
Mailing Address - Fax:773-283-0205
Practice Address - Street 1:5600 W ADDISON ST
Practice Address - Street 2:STE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4401
Practice Address - Country:US
Practice Address - Phone:773-283-2448
Practice Address - Fax:773-283-0205
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052035207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052035Medicaid
L62382Medicare ID - Type Unspecified
IL036052035Medicaid