Provider Demographics
NPI:1508867300
Name:SHAH, SYED AHMED (MD)
Entity Type:Individual
Prefix:DR
First Name:SYED
Middle Name:AHMED
Last Name:SHAH
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:PO BOX 431
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-9107
Mailing Address - Country:US
Mailing Address - Phone:618-533-9577
Mailing Address - Fax:618-533-9588
Practice Address - Street 1:1007 ML KING DR
Practice Address - Street 2:SUITE 1
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3003
Practice Address - Country:US
Practice Address - Phone:618-533-9577
Practice Address - Fax:618-533-9588
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360972352084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203013Medicare ID - Type Unspecified
ILH03629Medicare UPIN