Organization
LAKE SHORE OB GYN OF DECATUR S C
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ADEL SAMY HANNA M.D. (OWNER)
(217) 429-4119
Entity
Organization
Contact information
Practice address
741 W PERSHING RD, DECATUR, IL 62526-1634
(217) 429-4119
(217) 429-0108
Mailing address
1770 E LAKE SHORE DR, SUITE 303, DECATUR, IL 62521-3832
(217) 429-4119
(217) 429-0108
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036110172
—
IL
01
—
05832038
BLUE CROSS BLUE SHIELD
IL
01
—
634112
HEALTH LINK
—
Enumeration date
02/06/2007
Last updated
05/13/2025
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