Basic Information
| Provider Information | |||||||||
| NPI: | 1700382967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | SHIVALI | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2180 PFINGSTEN RD STE 3100 | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600261339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478667846 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2180 PFINGSTEN RD STE 3100 | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600261339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478667846 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2018 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125.071777 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 12194791-1204 | UT | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207QS0010X | 036161267 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.