Provider Demographics
NPI:1659467793
Name:FRY, SHAWN M (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:M
Last Name:FRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:M
Other - Last Name:HEMBROUGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2403
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:610 N. WESTGATE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650
Practice Address - Country:US
Practice Address - Phone:217-245-9931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-108501207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108501Medicaid
ILK23806Medicare PIN