Healthcare Provider Details

I. General information

NPI: 1164418067
Provider Name (Legal Business Name): WILLIAM H SHACKELFORD MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N VINE ST
ARTHUR IL
61911-1137
US

IV. Provider business mailing address

525 N VINE ST
ARTHUR IL
61911-1137
US

V. Phone/Fax

Practice location:
  • Phone: 217-543-3628
  • Fax: 217-543-2921
Mailing address:
  • Phone: 217-543-3628
  • Fax: 217-543-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: WILLIAM H SHACKELFORD
Title or Position: OWNER
Credential: MD
Phone: 217-543-3628