Provider Demographics
NPI:1770517070
Name:SHAH, SHITAL B (MD)
Entity type:Individual
Prefix:
First Name:SHITAL
Middle Name:B
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:OLOPI
Other - Middle Name:C
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3800 W ESTES AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-1032
Mailing Address - Country:US
Mailing Address - Phone:773-383-0006
Mailing Address - Fax:847-983-0686
Practice Address - Street 1:1515 LAKE ST
Practice Address - Street 2:ALEXIAN BROTHER ST ALEXIUS MEDICAL CENTER
Practice Address - City:HANOVER PARK
Practice Address - State:IL
Practice Address - Zip Code:60133
Practice Address - Country:US
Practice Address - Phone:847-472-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058187207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619414OtherBCBS GROUP
IL036058187Medicaid
1619414OtherBCBS GROUP
739531009 ICCMedicare PIN
K27452Medicare PIN
K27463Medicare PIN
D13890Medicare UPIN
216966001 EP/DPMedicare PIN
ILK37807Medicare PIN