Provider Demographics
NPI:1174672331
Name:SHAY, THANAD S (MD)
Entity Type:Individual
Prefix:DR
First Name:THANAD
Middle Name:S
Last Name:SHAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 N NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1533
Mailing Address - Country:US
Mailing Address - Phone:309-671-2310
Mailing Address - Fax:
Practice Address - Street 1:1201 N NORTH ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1533
Practice Address - Country:US
Practice Address - Phone:309-671-2310
Practice Address - Fax:309-674-3560
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048357207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048357Medicaid
ILC39816Medicare UPIN
IL036048357Medicaid