Provider Demographics
NPI:1992752299
Name:SHAH, GHANSHYAM M (MD)
Entity type:Individual
Prefix:
First Name:GHANSHYAM
Middle Name:M
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 1:5999 NEW WILKE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-4502
Mailing Address - Country:US
Mailing Address - Phone:847-255-7107
Mailing Address - Fax:847-255-7031
Practice Address - Street 1:5999 NEW WILKE RD
Practice Address - Street 2:SUITE 200 BLDG 2
Practice Address - City:ROLLING MEADOWS
Practice Address - State:IL
Practice Address - Zip Code:60008-4506
Practice Address - Country:US
Practice Address - Phone:847-255-7107
Practice Address - Fax:847-255-7031
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096146207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG69310Medicare UPIN