Provider Demographics
NPI:1104832377
Name:SHELAT, SURESH G (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:G
Last Name:SHELAT
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 1:100 N 20TH ST
Mailing Address - Street 2:CHOP SUITE 301
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1443
Mailing Address - Country:US
Mailing Address - Phone:215-567-2422
Mailing Address - Fax:215-561-0959
Practice Address - Street 1:34TH & CIVIC CENTER BLVD
Practice Address - Street 2:CHILDREN'S HOSPITAL OF PHILADELPHIA
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-1000
Practice Address - Fax:215-561-0959
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD418146207ZP0105X, 2080P0207X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Not Answered2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0006971Medicaid
NJ0006971Medicaid
I00681Medicare UPIN