Healthcare Provider Details

I. General information

NPI: 1346495546
Provider Name (Legal Business Name): SHAWN ANDREW MAYER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2008
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER ST DEPT OF
SPRINGFIELD IL
62769-1000
US

IV. Provider business mailing address

111 OAKWOOD RD
EAST PEORIA IL
61611-1853
US

V. Phone/Fax

Practice location:
  • Phone: 217-544-4780
  • Fax: 217-757-6431
Mailing address:
  • Phone: 309-655-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-137487
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD29447
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD29447
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036-137487
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: