1134481211 NPI number — BIRVA K SHAH O.D.

Table of content: BIRVA K SHAH O.D. (NPI 1134481211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134481211 NPI number — BIRVA K SHAH O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAH
Provider First Name:
BIRVA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KADAKIA
Provider Other First Name:
BIRVA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134481211
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4684 DEPT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAROL STREAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60122-4684
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-423-4192
Provider Business Mailing Address Fax Number:
708-952-0329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10436 SOUTHWEST HWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CHICAGO RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60415-2282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-423-4192
Provider Business Practice Location Address Fax Number:
708-952-0329
Provider Enumeration Date:
06/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046010543 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WP0200X , with the licence number: 046010543 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01621679 . This is a "BLUE CROSS & BLUE SHEILD ESC # 01621679" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 200871680 . This is a "INDIANA GROUP MEDICAID LEGACY PTAN # 200871680" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 046010543 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1083684922 . This is a "THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1083684922" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1700191012 . This is a "UNIVERSITY OF CHICAGO MEDICAL CENTER NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CK7818 . This is a "RAILROAD MEDICARE ESC GROUP# CK7818" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1083684922 . This is a "THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1083684922" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 12385422 . This is a "CAQH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1699802421 . This is a "OPTICAL THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1699802421" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 502720062 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 14D2054175 . This is a "CLIA # 14D2054175 EXP 2-14-2015 CHICAGO RIDGE LOCATION" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 253350 . This is a "INDIANA MEDICARE GROUP PTAN 253350" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 253350 . This is a "ILLINOIS MEDICARE GROUP PTAN 253350" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 6180260001 . This is a "DEMERC SUPPLIER PTAN 6180260001 THE EYE SPECIALISTS CENTER, LLC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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