Healthcare Provider Details

I. General information

NPI: 1811560881
Provider Name (Legal Business Name): SHEMARIAH LAISH ISRAEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RICHMOND AVE E STE 1
MATTOON IL
61938-4652
US

IV. Provider business mailing address

PO BOX 372
MATTOON IL
61938-0372
US

V. Phone/Fax

Practice location:
  • Phone: 217-234-7000
  • Fax: 217-234-7011
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.080277
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.173647
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: