Healthcare Provider Details

I. General information

NPI: 1427072768
Provider Name (Legal Business Name): SAMIR K SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 STATE ROUTE 162 STE 102
MARYVILLE IL
62062-8560
US

IV. Provider business mailing address

PO BOX 959203
SAINT LOUIS MO
63195-9203
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-4076
  • Fax: 618-288-4215
Mailing address:
  • Phone: 618-288-4076
  • Fax: 618-288-4215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number036-063403
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036-063403
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036-063403
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: