Provider Demographics
NPI:1245260066
Name:SHAH, NIRAV C (MD)
Entity type:Individual
Prefix:
First Name:NIRAV
Middle Name:C
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 1:3929 MERCY DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-3151
Mailing Address - Country:US
Mailing Address - Phone:815-759-0800
Mailing Address - Fax:815-759-2367
Practice Address - Street 1:4201 W MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8409
Practice Address - Country:US
Practice Address - Phone:815-334-5566
Practice Address - Fax:815-759-4008
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360911542085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360911541Medicaid
ILG73123Medicare UPIN
IL0360911541Medicaid
ILK20480Medicare ID - Type UnspecifiedPROVIDER NUMBER