Basic Information
| Provider Information | |||||||||
| NPI: | 1679093413 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | MANSI | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2150 WEST HARRISON STREET | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129425000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2150 WEST HARRISON STREET | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129425000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2017 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MT219577 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0804X | 036159871 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | MT219577 | 01 | PA | PA SATE LICENSE | OTHER |