Provider Demographics
NPI:1033104948
Name:SHETTY, BALU B (MD)
Entity Type:Individual
Prefix:
First Name:BALU
Middle Name:B
Last Name:SHETTY
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 1:585 RUGH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-5667
Mailing Address - Country:US
Mailing Address - Phone:724-838-1534
Mailing Address - Fax:724-838-1536
Practice Address - Street 1:8775 NORWIN AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:N HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:15642-2718
Practice Address - Country:US
Practice Address - Phone:724-864-0503
Practice Address - Fax:724-864-0535
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039618L207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001171343001Medicaid
PA469329OtherBS
E23162Medicare UPIN
PASH469324Medicare ID - Type Unspecified