Healthcare Provider Details

I. General information

NPI: 1417940354
Provider Name (Legal Business Name): TRUDY M SHADY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DR STE 200
BELLEVILLE IL
62226-5363
US

IV. Provider business mailing address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-2220
  • Fax: 618-233-2555
Mailing address:
  • Phone: 618-257-4644
  • Fax: 618-257-6946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberR3L47
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-089376
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036-089376
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: