Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 125.070237 | IL |
Y | 207QS0010X | Family Doctor - Sports Medicine | 036.149951 | IL |
NPI | 1326579103 |
---|---|
Provider Name | Ravi Shah |
First Address | Tinley Park, IL 60477-6208 |
Second Address | Tinley Park, IL 60477-6208 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2017 |
Last Update Date | 21/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1326579103 | (05) | IL |