Provider Demographics
NPI:1265521587
Name:SHETH, SUSHIL A (MD)
Entity type:Individual
Prefix:
First Name:SUSHIL
Middle Name:A
Last Name:SHETH
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:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-0157
Mailing Address - Country:US
Mailing Address - Phone:630-321-0097
Mailing Address - Fax:630-321-0909
Practice Address - Street 1:1 INGALLS DR
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-3558
Practice Address - Country:US
Practice Address - Phone:630-321-0097
Practice Address - Fax:630-321-0909
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081476207RC0000X
IN01044948A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1626060OtherBLUE SHIELD
IL364228422OtherCOMMERCIAL INSURANCE
IL036081476Medicaid
IL036081476Medicaid
IL380951Medicare PIN
IL1626060OtherBLUE SHIELD