Provider Demographics
NPI:1184706988
Name:SHALLAT, SHELLY
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:SHALLAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3172
Mailing Address - Country:US
Mailing Address - Phone:309-680-7600
Mailing Address - Fax:309-495-8614
Practice Address - Street 1:10 SAINT CLARE CT
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-9239
Practice Address - Country:US
Practice Address - Phone:309-886-4000
Practice Address - Fax:309-886-4118
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101025208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101025Medicaid
IL07223454OtherBLUE CROSS
ILIL20810OtherBEECH STREET
ILK16654Medicare ID - Type UnspecifiedINDIVIDUAL #
IL07223454OtherBLUE CROSS
IL207594Medicare ID - Type UnspecifiedGROUP #