Healthcare Provider Details

I. General information

NPI: 1477567394
Provider Name (Legal Business Name): HYTHEM P SHADID M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 FOXFIELD RD SUITE 102
ST CHARLES IL
60174-5799
US

IV. Provider business mailing address

2900 FOXFIELD RD SUITE 102
ST CHARLES IL
60174-5799
US

V. Phone/Fax

Practice location:
  • Phone: 630-377-1188
  • Fax: 630-377-7360
Mailing address:
  • Phone: 630-377-1188
  • Fax: 630-377-7360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036082388
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: