Provider Demographics
NPI:1013906411
Name:SHAW, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:SHAW
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 1:25068 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-0001
Mailing Address - Country:US
Mailing Address - Phone:847-585-7000
Mailing Address - Fax:857-240-0622
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:STE 2140
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-664-5400
Practice Address - Fax:312-664-5854
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042608207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042608Medicaid
ILL56360Medicare PIN
IL036042608Medicaid
IL410032473Medicare PIN