Provider Demographics
NPI:1720086960
Name:SHAW, CHARLES T (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
Last Name:SHAW
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 1:6084 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2747
Mailing Address - Country:US
Mailing Address - Phone:773-355-2800
Mailing Address - Fax:
Practice Address - Street 1:6084 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2747
Practice Address - Country:US
Practice Address - Phone:773-355-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078790207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078790Medicaid
IL036078790Medicaid
ILCL4550OtherRAILROAD GROUP #
IL036078790Medicaid
ILCL4550OtherRAILROAD GROUP #