Healthcare Provider Details

I. General information

NPI: 1598438137
Provider Name (Legal Business Name): MAHAM SHAHID MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 11/18/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 IL-91 STE 130
PEORIA IL
61615
US

IV. Provider business mailing address

8600 IL - 91 STE 130
PEORIA IL
61615
US

V. Phone/Fax

Practice location:
  • Phone: 309-683-5050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.172001
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036172001
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number036.172001
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: