1487753596 NPI number — SHAMSHAD A. ANJUM MD

Table of content: SHAMSHAD A. ANJUM MD (NPI 1487753596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487753596 NPI number — SHAMSHAD A. ANJUM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANJUM
Provider First Name:
SHAMSHAD
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487753596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1905 E. HUEBBE PARKWAY
Provider Second Line Business Mailing Address:
BELOIT HEALTH SYSTEM INC.
Provider Business Mailing Address City Name:
BELOIT
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53511-1842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-364-2293
Provider Business Mailing Address Fax Number:
608-363-7395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1735 MADISON ROAD
Provider Second Line Business Practice Location Address:
WESTSIDE CLINIC
Provider Business Practice Location Address City Name:
BELOIT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53511-3216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-363-7510
Provider Business Practice Location Address Fax Number:
608-363-7528
Provider Enumeration Date:
09/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036085335 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 35977-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1487753596 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".