Provider Demographics
NPI:1316935240
Name:SHAH, PRABODH C (MD)
Entity type:Individual
Prefix:
First Name:PRABODH
Middle Name:C
Last Name:SHAH
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 1:2800 W 95TH ST
Mailing Address - Street 2:CANCER CENTER
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2701
Mailing Address - Country:US
Mailing Address - Phone:708-229-6020
Mailing Address - Fax:708-229-6083
Practice Address - Street 1:2800 W 95TH ST
Practice Address - Street 2:CANCER CENTER
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2701
Practice Address - Country:US
Practice Address - Phone:708-229-6020
Practice Address - Fax:708-229-6083
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042091207RH0003X
CAA25747207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042091OtherLICENSE
IL036042091Medicaid
CAM050376OtherGROUP
CA00A257470Medicaid
CA00A257470Medicaid
ILT01700Medicare PIN
IL036042091Medicaid