Provider Demographics
NPI:1740499573
Name:SMITA J SHAH, MD
Entity type:Organization
Organization Name:SMITA J SHAH, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLYAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-897-5995
Mailing Address - Street 1:PO BOX 5979
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-5979
Mailing Address - Country:US
Mailing Address - Phone:847-897-5995
Mailing Address - Fax:847-897-5990
Practice Address - Street 1:6905 CERMAK RD STE A
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2175
Practice Address - Country:US
Practice Address - Phone:708-749-0091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty