Provider Demographics
NPI:1649362443
Name:BOSE, SHYAMAL (MD)
Entity type:Individual
Prefix:
First Name:SHYAMAL
Middle Name:
Last Name:BOSE
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 1:3030 CHICAGO RD
Mailing Address - Street 2:3030 CHICAGO ROAD
Mailing Address - City:STEGER
Mailing Address - State:IL
Mailing Address - Zip Code:60475-1055
Mailing Address - Country:US
Mailing Address - Phone:708-756-3037
Mailing Address - Fax:
Practice Address - Street 1:3030 CHICAGO RD
Practice Address - Street 2:3030 CHICAGO ROAD
Practice Address - City:STEGER
Practice Address - State:IL
Practice Address - Zip Code:60475-1055
Practice Address - Country:US
Practice Address - Phone:708-756-3037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-046084207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD12457Medicare UPIN