Provider Demographics
NPI:1316135841
Name:UDAY SHAH MD SC
Entity type:Organization
Organization Name:UDAY SHAH MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:UDAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-221-4645
Mailing Address - Street 1:9133 S STONY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3936
Mailing Address - Country:US
Mailing Address - Phone:773-221-4645
Mailing Address - Fax:773-221-4849
Practice Address - Street 1:9133 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3936
Practice Address - Country:US
Practice Address - Phone:773-221-4645
Practice Address - Fax:773-221-4849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057749207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31600160OtherBLUE CROSS BLUE SHIELD
IL036057749Medicaid
IN000000326579OtherBLUE CROSS BLUE SHIELD
IN200074090BMedicaid
060001645OtherRAILROAD MEDICARE
INC41890Medicare UPIN
IL036057749Medicaid
ILC41890Medicare UPIN
IN875950Medicare PIN