=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477567394
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HYTHEM P SHADID M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 04/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 FOXFIELD RD SUITE 102
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174-5799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-377-1188
-----------------------------------------------------
Fax | 630-377-7360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 FOXFIELD RD SUITE 102
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174-5799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-377-1188
-----------------------------------------------------
Fax | 630-377-7360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | 036082388
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------