Provider Demographics
NPI:1154341436
Name:SHAH, AKTA DINESH (MSPT)
Entity type:Individual
Prefix:
First Name:AKTA
Middle Name:DINESH
Last Name:SHAH
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 W LAKE AVE
Mailing Address - Street 2:SUITE #200
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1223
Mailing Address - Country:US
Mailing Address - Phone:847-998-1188
Mailing Address - Fax:
Practice Address - Street 1:3703 W LAKE AVE
Practice Address - Street 2:SUITE #200
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1223
Practice Address - Country:US
Practice Address - Phone:847-998-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-012688174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1618443OtherBCBS GROUP NO.
IL236963283001Medicaid
IL200573902OtherGROUP TAX ID
IL363396874OtherGROUP TAX ID
IL01634372OtherBCBS GROUP NO.
IL236963283001Medicaid
IL363396874OtherGROUP TAX ID
IL210877Medicare ID - Type UnspecifiedMEDICARE GROUP NO.
ILK34778Medicare ID - Type UnspecifiedBCI MEDIC. NO.
IL208324004Medicare PIN