=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427072768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMIR K SHAH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 11/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6810 STATE ROUTE 162 STE 102
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62062-8560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-288-4076
-----------------------------------------------------
Fax | 618-288-4215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 959203
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63195-9203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-288-4076
-----------------------------------------------------
Fax | 618-288-4215
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0000X
-----------------------------------------------------
Taxonomy Name | Adolescent Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 036-063403
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 036-063403
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 036-063403
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------