Provider Demographics
NPI:1942203971
Name:SHAMSHAM, FADI MICHEL (MD)
Entity Type:Individual
Prefix:DR
First Name:FADI
Middle Name:MICHEL
Last Name:SHAMSHAM
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 1:4115 S. WATER TOWER PLACE
Mailing Address - Street 2:P.O.BOX 1003
Mailing Address - City:MT. VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-204-5462
Mailing Address - Fax:618-204-5472
Practice Address - Street 1:4115 S. WATER TOWER PLACE
Practice Address - Street 2:
Practice Address - City:MT. VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-204-5462
Practice Address - Fax:618-204-5472
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123701207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123701Medicaid
ILPTAN IL2386Medicare PIN
FLH61853Medicare UPIN