Provider Demographics
NPI:1720028632
Name:SHAH, SAMIR H (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:H
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 1:1302 FRANKLIN AVE
Mailing Address - Street 2:#4500
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3551
Mailing Address - Country:US
Mailing Address - Phone:309-828-1166
Mailing Address - Fax:309-862-0330
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:#4500
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:309-828-1166
Practice Address - Fax:309-862-0330
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05732097OtherBC GROUP NUMBER
IL027294OtherHEALTH ALLIANCE
ILK22990Medicare ID - Type Unspecified
IL212636Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
ILP00272621Medicare UPIN
IL05732097OtherBC GROUP NUMBER