Healthcare Provider Details

I. General information

NPI: 1669789327
Provider Name (Legal Business Name): MARK T. SHIMA D. O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 S 1ST ST
CHAMPAIGN IL
61820-7661
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-9400
  • Fax: 217-383-9691
Mailing address:
  • Phone: 217-383-6941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036142552
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number036142552
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: