Provider Demographics
NPI:1245236884
Name:SHAWAHIN, NIDAL (MD)
Entity type:Individual
Prefix:
First Name:NIDAL
Middle Name:
Last Name:SHAWAHIN
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 1:4600 MEMORIAL DR
Mailing Address - Street 2:STE. 360
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5368
Mailing Address - Country:US
Mailing Address - Phone:618-222-7280
Mailing Address - Fax:618-222-7281
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:STE. 360
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5368
Practice Address - Country:US
Practice Address - Phone:618-222-7280
Practice Address - Fax:618-222-7281
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087648207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087648Medicaid
IL036087648Medicaid
ILF89477Medicare UPIN