Basic Information
| Provider Information | |||||||||
| NPI: | 1508853979 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | DIPAK | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2009 MIDWEST CLUB PKWY | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605232526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302727950 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5454 HOHMAN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463201931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199332270 | ||||||||
| FaxNumber: | 2198522515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 01/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01055335A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 200404970 | 05 | IN | MEDICAID |