Provider Demographics
NPI:1255591632
Name:SHAH, SHIVANI PANKAJ (MD)
Entity type:Individual
Prefix:DR
First Name:SHIVANI
Middle Name:PANKAJ
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12 SALT CREEK LN
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-8605
Mailing Address - Country:US
Mailing Address - Phone:630-856-2731
Mailing Address - Fax:630-323-0260
Practice Address - Street 1:12 SALT CREEK LN
Practice Address - Street 2:SUITE 106
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-8605
Practice Address - Country:US
Practice Address - Phone:630-856-2731
Practice Address - Fax:630-323-0260
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.120677282NC2000X
IL0361206772080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
399980OtherMEDICARE GROUP PTAN