Provider Demographics
NPI:1396799037
Name:MAYFAIR FAMILYCARE SC
Entity type:Organization
Organization Name:MAYFAIR FAMILYCARE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BHARAT
Authorized Official - Middle Name:KANTILAL
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-271-6622
Mailing Address - Street 1:5115 N FRANCISCO AVE
Mailing Address - Street 2:FL 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3611
Mailing Address - Country:US
Mailing Address - Phone:773-271-6622
Mailing Address - Fax:773-271-6801
Practice Address - Street 1:5115 N FRANCISCO AVE
Practice Address - Street 2:FL 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3611
Practice Address - Country:US
Practice Address - Phone:773-271-6622
Practice Address - Fax:773-271-6801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2015-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042007954207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
110169119OtherRAILROAD MEDICARE
IL21605075OtherBLUE CROSS
IL21605075OtherBLUE CROSS