Provider Demographics
| NPI: | 1134481211 |
|---|---|
| Name: | SHAH, BIRVA K (OD) |
| Entity type: | Individual |
| Prefix: | |
| First Name: | BIRVA |
| Middle Name: | K |
| Last Name: | SHAH |
| Suffix: | |
| Gender: | F |
| Credentials: | OD |
| Other - Prefix: | |
| Other - First Name: | BIRVA |
| Other - Middle Name: | A |
| Other - Last Name: | KADAKIA |
| Other - Suffix: | |
| Other - Last Name Type: | Former Name |
| Other - Credentials: | OD |
| Mailing Address - Street 1: | 4684 DEPT |
| Mailing Address - Street 2: | |
| Mailing Address - City: | CAROL STREAM |
| Mailing Address - State: | IL |
| Mailing Address - Zip Code: | 60122-4684 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 708-423-4192 |
| Mailing Address - Fax: | 708-952-0329 |
| Practice Address - Street 1: | 10436 SOUTHWEST HWY |
| Practice Address - Street 2: | SUITE 101 |
| Practice Address - City: | CHICAGO RIDGE |
| Practice Address - State: | IL |
| Practice Address - Zip Code: | 60415-2282 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 708-423-4192 |
| Practice Address - Fax: | 708-952-0329 |
| Is Sole Proprietor?: | No |
| Enumeration Date: | 2012-06-13 |
| Last Update Date: | 2013-10-18 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| IL | 046010543 | 152W00000X, 152WP0200X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 152W00000X | Eye and Vision Services Providers | Optometrist | |
| No | 152WP0200X | Eye and Vision Services Providers | Optometrist | Pediatrics |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| IL | 01621679 | Other | BLUE CROSS & BLUE SHEILD ESC # 01621679 |
| IN | 200871680 | Other | INDIANA GROUP MEDICAID LEGACY PTAN # 200871680 |
| IL | 046010543 | Medicaid | |
| IN | 1083684922 | Other | THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1083684922 |
| IL | 1700191012 | Other | UNIVERSITY OF CHICAGO MEDICAL CENTER NPI |
| IL | CK7818 | Other | RAILROAD MEDICARE ESC GROUP# CK7818 |
| IL | 1083684922 | Other | THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1083684922 |
| IL | 12385422 | Other | CAQH |
| IL | 1699802421 | Other | OPTICAL THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1699802421 |
| IL | 502720062 | Other | MEDICARE PTAN |
| IL | 14D2054175 | Other | CLIA # 14D2054175 EXP 2-14-2015 CHICAGO RIDGE LOCATION |
| IN | 253350 | Other | INDIANA MEDICARE GROUP PTAN 253350 |
| IL | 253350 | Other | ILLINOIS MEDICARE GROUP PTAN 253350 |
| IL | 6180260001 | Other | DEMERC SUPPLIER PTAN 6180260001 THE EYE SPECIALISTS CENTER, LLC |
| IL | 01621679 | Other | BLUE CROSS & BLUE SHEILD ESC # 01621679 |
| IN | 1083684922 | Other | THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1083684922 |
| IL | 14D2054175 | Other | CLIA # 14D2054175 EXP 2-14-2015 CHICAGO RIDGE LOCATION |
| IL | CK7818 | Other | RAILROAD MEDICARE ESC GROUP# CK7818 |
