Provider Demographics
NPI:1861420713
Name:SHAH, ILA (MD)
Entity type:Individual
Prefix:
First Name:ILA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8419 S COTTAGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-6113
Mailing Address - Country:US
Mailing Address - Phone:773-651-0200
Mailing Address - Fax:773-651-8968
Practice Address - Street 1:8419 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6113
Practice Address - Country:US
Practice Address - Phone:773-651-0200
Practice Address - Fax:773-651-8968
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061434207Q00000X
IN0104012B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061434Medicaid
IL21609496OtherBCBS
IL673850Medicare ID - Type Unspecified
IL21609496OtherBCBS