Provider Demographics
NPI:1811080716
Name:SHAH, MANZOOR HUSSAIN (MD)
Entity type:Individual
Prefix:
First Name:MANZOOR
Middle Name:HUSSAIN
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MANZOOR
Other - Middle Name:
Other - Last Name:HUSSAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1479 RING RD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409
Mailing Address - Country:US
Mailing Address - Phone:708-891-2181
Mailing Address - Fax:708-891-2188
Practice Address - Street 1:1479 RING RD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409
Practice Address - Country:US
Practice Address - Phone:708-891-2181
Practice Address - Fax:708-891-2188
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 049259207RP1001X
IN01031445207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036049259Medicaid
IN100005670BOtherPUBLIC AID
IN100005670BOtherPUBLIC AID
D13137Medicare UPIN
IL492500Medicare ID - Type Unspecified