Provider Demographics
NPI:1043381734
Name:SUBBANNA, SHASHIDHAR (MD)
Entity Type:Individual
Prefix:
First Name:SHASHIDHAR
Middle Name:
Last Name:SUBBANNA
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 1:2151 GRAMERCY PL
Mailing Address - Street 2:
Mailing Address - City:HUMMELSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17036-7061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2151 GRAMERCY PL
Practice Address - Street 2:
Practice Address - City:HUMMELSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17036-7061
Practice Address - Country:US
Practice Address - Phone:717-851-0867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080116207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA060574603AMedicaid
GAP00403426OtherRRMEDICARE
SCG56928Medicaid
GA198495OtherBCBS
GA060574603BMedicaid
GA339365OtherWELLCARE CMO
GA550789920OtherTRICARE
GA05BDKWFMedicare ID - Type Unspecified
GAI44237Medicare UPIN