Provider Demographics
NPI:1073129433
Name:MITCHEM, SHAMIA M
Entity Type:Individual
Prefix:
First Name:SHAMIA
Middle Name:M
Last Name:MITCHEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 LINCOLN HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1938
Mailing Address - Country:US
Mailing Address - Phone:708-852-3171
Mailing Address - Fax:708-852-3211
Practice Address - Street 1:2555 LINCOLN HWY STE 104
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1938
Practice Address - Country:US
Practice Address - Phone:708-852-3171
Practice Address - Fax:708-852-3211
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory