Provider Demographics
NPI:1487920252
Name:K S SHAH MD SC
Entity type:Organization
Organization Name:K S SHAH MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-799-5420
Mailing Address - Street 1:17680 KEDZIE AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2043
Mailing Address - Country:US
Mailing Address - Phone:708-799-5420
Mailing Address - Fax:708-799-4093
Practice Address - Street 1:17680 KEDZIE AVE
Practice Address - Street 2:STE 201
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2043
Practice Address - Country:US
Practice Address - Phone:708-799-5420
Practice Address - Fax:708-799-4093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-048096207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD12565Medicare UPIN