1184636805 NPI number — SHAKU CHHABRIA NEUROLOGICAL SERVICES SC

Table of content: (NPI 1184636805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184636805 NPI number — SHAKU CHHABRIA NEUROLOGICAL SERVICES SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHAKU CHHABRIA NEUROLOGICAL SERVICES SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHHABRIA NEUROLOGICAL SERVICES
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184636805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 S GREENLEAF ST STE 111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GURNEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60031-5705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-360-0044
Provider Business Mailing Address Fax Number:
847-360-8804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 S GREENLEAF ST STE 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GURNEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60031-5705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-360-0044
Provider Business Practice Location Address Fax Number:
847-360-8804
Provider Enumeration Date:
08/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHHABRIA
Authorized Official First Name:
SHAKUNTALA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
847-360-0044

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  036053149 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084N0402X , with the licence number: 036053149 , 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: DE1546 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036053149 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4900918 . This is a "BLUE CROSS/SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".