Provider Demographics
NPI:1487753596
Name:ANJUM, SHAMSHAD A (MD)
Entity type:Individual
Prefix:
First Name:SHAMSHAD
Middle Name:A
Last Name:ANJUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 E. HUEBBE PARKWAY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC.
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2293
Mailing Address - Fax:608-363-7395
Practice Address - Street 1:1735 MADISON ROAD
Practice Address - Street 2:WESTSIDE CLINIC
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3216
Practice Address - Country:US
Practice Address - Phone:608-363-7510
Practice Address - Fax:608-363-7528
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085335207Q00000X
WI35977-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1487753596Medicaid
WI1487753596Medicaid