Provider Demographics
NPI:1912997743
Name:SHAFI, AHMED (MD)
Entity Type:Individual
Prefix:DR
First Name:AHMED
Middle Name:
Last Name:SHAFI
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 1:1368 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1410
Mailing Address - Country:US
Mailing Address - Phone:815-942-8080
Mailing Address - Fax:815-942-0843
Practice Address - Street 1:4829 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-4234
Practice Address - Country:US
Practice Address - Phone:773-927-2714
Practice Address - Fax:773-927-2716
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-098168Medicaid
IL03222998OtherBCBS
ILK14818Medicare PIN
IL03222998OtherBCBS
ILG69417Medicare UPIN