Basic Information
| Provider Information | |||||||||
| NPI: | 1669784872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UDDIN | ||||||||
| FirstName: | SHAHAAB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 ERIE CT | ||||||||
| Address2: | SUITE L-700 | ||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603022519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087631222 | ||||||||
| FaxNumber: | 7087631471 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 STATE ST | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471504990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129447701 | ||||||||
| FaxNumber: | 8129816505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2010 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125058873 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 01073189B | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 036131145 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 201187680 | 05 | IN | MEDICAID | 036131145 | 01 | IL | STATE LICENSE | OTHER |