Provider Demographics
NPI:1497984389
Name:SOUTHERN ILLINOIS HEART AND VASCULAR CENTER, PC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS HEART AND VASCULAR CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:MICHEL
Authorized Official - Last Name:SHAMSHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-735-8419
Mailing Address - Street 1:P.O.BOX 1003
Mailing Address - Street 2:
Mailing Address - City:MT. VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6293
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4115 SOUTH WATER TOWER PLACE
Practice Address - Street 2:
Practice Address - City:MT. VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6293
Practice Address - Country:US
Practice Address - Phone:941-735-8419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123701207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty