Provider Demographics
NPI:1992792394
Name:SHAH, AMIT G (MD)
Entity type:Individual
Prefix:DR
First Name:AMIT
Middle Name:G
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 1:22285 PEPPER RD.
Mailing Address - Street 2:#311
Mailing Address - City:LAKE BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010
Mailing Address - Country:US
Mailing Address - Phone:847-382-4410
Mailing Address - Fax:847-382-4451
Practice Address - Street 1:22285 PEPPER RD.
Practice Address - Street 2:#311
Practice Address - City:LAKE BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010
Practice Address - Country:US
Practice Address - Phone:847-382-4410
Practice Address - Fax:847-382-4451
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-099527207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-099527Medicaid
IL036-099527OtherPHYSICIAN LICENSE
IL036-099527OtherPHYSICIAN LICENSE
K00757Medicare ID - Type UnspecifiedLOCALITY 15
G78837Medicare UPIN