Healthcare Provider Details

I. General information

NPI: 1437151271
Provider Name (Legal Business Name): SHANTHA MATTHEW MONIPPALLIL M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANTHA MATTHEW MONIPPALLIL M.D

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 S 4TH ST SAME
EFFINGHAM IL
62401-4187
US

IV. Provider business mailing address

1901 S 4TH ST SAME
EFFINGHAM IL
62401-4187
US

V. Phone/Fax

Practice location:
  • Phone: 217-347-7600
  • Fax:
Mailing address:
  • Phone: 217-347-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036058112
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: