Provider Demographics
NPI:1013213776
Name:MADAHAR, SHAUN (MD)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:MADAHAR
Suffix:
Gender:M
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5754
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:200 E CHESTNUT ST
Practice Address - Street 2:SERVICE BUILDING SUITE 303
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1831
Practice Address - Country:US
Practice Address - Phone:502-629-5552
Practice Address - Fax:502-629-3132
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127851207R00000X
VA0101254825207R00000X
IN01076265A208M00000X
PAMD454367208M00000X
KY46502207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100263820Medicaid