Provider Demographics
NPI:1417992520
Name:ALTWAL, SHADI ADEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SHADI
Middle Name:ADEL
Last Name:ALTWAL
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 1:4500 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5360
Mailing Address - Country:US
Mailing Address - Phone:618-257-6220
Mailing Address - Fax:618-257-6679
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-257-6220
Practice Address - Fax:618-257-6679
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-112737208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL106079OtherHEALTH ALLIANCE
IL036112737Medicaid
IL08726591OtherBCBS
IL717755OtherHEALTHLINK
IL036112737Medicaid
ILI30762Medicare UPIN