Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 036068794 | IL |
Y | 208600000X | Surgeon | 036068794 | IL |
N | 2086S0102X | Surgical Critical Care | 036068794 | IL |
N | 2086S0127X | Trauma Surgeon | 036068794 | IL |
NPI | 1003920547 |
---|---|
Provider Name | Dr. Manoj Shah |
First Address | Park Ridge, IL 60068-1186 |
Second Address | Park Ridge, IL 60068-1186 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2006 |
Last Update Date | 20/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036068794 | (05) | IL |
C44404 | (02) | IL |