Provider Demographics
NPI:1457698748
Name:SHAH ALAM PC
Entity Type:Organization
Organization Name:SHAH ALAM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-306-7944
Mailing Address - Street 1:1057 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4033
Mailing Address - Country:US
Mailing Address - Phone:630-306-7944
Mailing Address - Fax:
Practice Address - Street 1:2701 W 68TH ST
Practice Address - Street 2:HOLY CROSS HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-1813
Practice Address - Country:US
Practice Address - Phone:773-884-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114268207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114268Medicaid
ILI45420Medicare UPIN