Provider Demographics
NPI:1326034232
Name:WILLIAM H SHACKELFORD MD
Entity Type:Organization
Organization Name:WILLIAM H SHACKELFORD MD
Other - Org Name:SHACKELFORD CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-763-5851
Mailing Address - Street 1:PO BOX 20
Mailing Address - Street 2:
Mailing Address - City:CERRO GORDO
Mailing Address - State:IL
Mailing Address - Zip Code:61818-0020
Mailing Address - Country:US
Mailing Address - Phone:217-763-5851
Mailing Address - Fax:217-763-2201
Practice Address - Street 1:208 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:CERRO GORDO
Practice Address - State:IL
Practice Address - Zip Code:62501
Practice Address - Country:US
Practice Address - Phone:217-763-5851
Practice Address - Fax:217-763-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0007423084OtherBLUE SHIELD
IL036034153-2Medicaid
IL036034153-2Medicaid