Provider Demographics
NPI:1215987003
Name:SHAH, BHADRA
Entity type:Individual
Prefix:DR
First Name:BHADRA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5906 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5420
Mailing Address - Country:US
Mailing Address - Phone:773-774-7300
Mailing Address - Fax:
Practice Address - Street 1:5906 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5420
Practice Address - Country:US
Practice Address - Phone:773-774-7300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632789OtherBC #
ILK19475Medicare ID - Type Unspecified
IL01632789OtherBC #