Provider Demographics
NPI:1760684765
Name:SHINNERL, ROGER SEBASTIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:SEBASTIAN
Last Name:SHINNERL
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 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:305 W JACKSON ST STE 206
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-457-3006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361669382086S0129X
IN01063822A2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100035620Medicaid
IN00001666778OtherBCBS
IN01063822AOtherSTATE LICENSE
IN01063822BOtherSTATE CSR
IN300063165Medicaid
IN01063822BOtherSTATE CSR
IL$$$$$$$$$-01Medicaid
INP00425173OtherRAILROAD MEDICARE