Provider Demographics
NPI:1801811914
Name:SHAMMA, MOHAMAD O (MD)
Entity type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:O
Last Name:SHAMMA
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 1:1505 EASTLAND DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1505 EASTLAND DR
Practice Address - Street 2:SUITE 320
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3534
Practice Address - Country:US
Practice Address - Phone:309-661-2368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCA2264Medicare ID - Type UnspecifiedRR GROUP #
ILP00342528Medicare ID - Type UnspecifiedRR INDIVIDUAL #
IL833120Medicare ID - Type UnspecifiedGROUP #
ILK28859Medicare ID - Type UnspecifiedINDIVIDUAL #
H94679Medicare UPIN