Provider Demographics
NPI:1235180043
Name:SHENOUDA, MOUNIR (MD)
Entity Type:Individual
Prefix:
First Name:MOUNIR
Middle Name:
Last Name:SHENOUDA
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 1:317 SALEM PLACE STE 140
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208
Mailing Address - Country:US
Mailing Address - Phone:618-632-3343
Mailing Address - Fax:618-632-4914
Practice Address - Street 1:317 SALEM PLACE STE 140
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208
Practice Address - Country:US
Practice Address - Phone:618-632-3343
Practice Address - Fax:618-632-4914
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360965361207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360965361Medicaid
G67949Medicare UPIN
ILL90629Medicare ID - Type Unspecified