MEDICARE: DR. EJAZ SHAMIM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	036.104277	IL
2	2085R0202X	Diagnostic Radiology Physician	01057985A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00086529	OTHER	IN	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548251069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EJAZ SHAMIM MD

Provider Business Mailing Address
First Line	:	9224 NAGLE AVE
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053-1428
Country	:	US
Telephone Number	:	847-966-7917
Fax Number	:

Provider Business Practice Location Address
First Line	:	9224 NAGLE AVE
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053-1428
Country	:	US
Telephone Number	:	847-966-7917
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	01/22/2014

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