Healthcare Provider Details

I. General information

NPI: 1568622686
Provider Name (Legal Business Name): SHADI JIBAWI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20201 CRAWFORD AVE
OLYMPIA FIELDS IL
60461-1010
US

IV. Provider business mailing address

6530 BELGIAN AVE
KALAMAZOO MI
49009-8985
US

V. Phone/Fax

Practice location:
  • Phone: 708-679-2160
  • Fax: 708-679-2161
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number03614632
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301092393
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036146320
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number03614632
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301092393
License Number StateMI
# 6
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036146320
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: