Provider Demographics
NPI:1487646972
Name:PARHAM, WALTER A (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:A
Last Name:PARHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2 GOOD SAMARITAN WAY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2408
Mailing Address - Country:US
Mailing Address - Phone:618-899-3900
Mailing Address - Fax:618-899-4786
Practice Address - Street 1:2 GOOD SAMARITAN WAY
Practice Address - Street 2:SUITE 220
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2408
Practice Address - Country:US
Practice Address - Phone:618-899-3900
Practice Address - Fax:618-899-4786
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036112518207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0010032059OtherBCBS
IL036112518Medicaid
MOBP5943445OtherDEA
IL036112518Medicaid
MOBP5943445OtherDEA
MOBP5943445OtherDEA
MOH08720Medicare UPIN