Provider Demographics
NPI:1811286552
Name:DEVINA SHAH SC
Entity type:Organization
Organization Name:DEVINA SHAH SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEVINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-468-9000
Mailing Address - Street 1:2315 E 93RD ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3936
Mailing Address - Country:US
Mailing Address - Phone:773-468-9000
Mailing Address - Fax:
Practice Address - Street 1:2315 E 93RD ST
Practice Address - Street 2:SUITE 340
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3936
Practice Address - Country:US
Practice Address - Phone:773-468-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059687Medicaid