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NPI Code Detail

MEDICARE: DR. SHAHEDA M MANSURI MD

MEDICARE: DR. SHAHEDA M MANSURI MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208D00000XGeneral Practice Physician036070613IL

General Provider Information

NPI Number : 1598701401
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SHAHEDA M MANSURI MD
Provider Business Mailing Address
First Line : PO BOX 155
Second Line :
City : CHRISTOPHER
State : IL
Zip : 62822-0155
Country : US
Telephone Number : 618-724-1624
Fax Number : 618-724-4628
Provider Business Practice Location Address
First Line : 1564 S WASHINGTON ST
Second Line :
City : DU QUOIN
State : IL
Zip : 62832-3849
Country : US
Telephone Number : 618-542-8702
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/20/2006
Last Update Date : 08/26/2019

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