Active NPI
Shima Phoenix, DMD
- Dentist
- Mount Vernon, IL
National Provider Identifier
1588040976
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 019.030430
- Practice address
- 4201 Broadway St
Mount Vernon, IL 62864-2282 - Phone
- (618) 241-0997
- NPI assigned
- Aug 7, 2015
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 019.030430 | IL | Primary |
Addresses
Primary practice location
4201 Broadway St
Mount Vernon, IL 62864-2282
Mailing address
4201 Broadway St
Mount Vernon, IL 62864-2282
Phone (618) 241-0997
Other names 1
- Shima Phoenix
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20180813003479 | IL | Order and Referring Only - Dentist | 8224387915 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019.030430 | IL | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Lavender Rose Dental | Current | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Dental Clinic/Center
- Chenoa, IL
- NPI 1902412158
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1438905600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1440028800000",
"number": "1588040976",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4201 BROADWAY ST",
"city": "MOUNT VERNON",
"state": "IL",
"postal_code": "628642282",
"telephone_number": "618-241-0997"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4201 BROADWAY ST",
"city": "MOUNT VERNON",
"state": "IL",
"postal_code": "628642282",
"telephone_number": "618-241-0997"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PHOENIX",
"first_name": "SHIMA",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2015-08-07",
"last_updated": "2015-08-20",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IL",
"license": "019.030430",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"first_name": "SHIMA",
"last_name": "PHOENIX",
"code": "2",
"type": "Professional Name"
}
]
}Other providers in Mount Vernon, IL
- Petersen Health Care LL, Inc.
- Petersen Management Company, LLC
- Petersen Management Company, LLC
- Cynthia Dawn Phillips, APN
- Jaylyn Phillips
- Physician Rural Health Clinic of Jefferson County
- Physician Services Corp of Southern Illinois
- Physician Services Corporation of Southern Illinois
- Physician Services Corporation of Southern Illinois Inc
- Physician Services Corporation of Southern Illinois Inc.
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 20, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.