Basic Information
| Provider Information | |||||||||
| NPI: | 1427072768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | SAMIR | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 N ROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712200 | ||||||||
| FaxNumber: | 8159719097 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 N ROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712200 | ||||||||
| FaxNumber: | 8159719097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0000X | 036-063403 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine | 207RG0300X | 036-063403 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RC0000X | 036-063403 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 036063403 | 05 | IL | MEDICAID | 01636052 | 01 | IL | BCBS | OTHER |