Provider Demographics
NPI:1104842913
Name:SHYAM VERMA MD PA
Entity Type:Organization
Organization Name:SHYAM VERMA MD PA
Other - Org Name:FLORIDA NEPHROLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:VERMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-267-1164
Mailing Address - Street 1:801 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3408
Mailing Address - Country:US
Mailing Address - Phone:321-267-1164
Mailing Address - Fax:321-267-8378
Practice Address - Street 1:801 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796
Practice Address - Country:US
Practice Address - Phone:321-267-1164
Practice Address - Fax:321-267-8378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0054560207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049633200Medicaid
FL049633200Medicaid
FLK0942Medicare ID - Type Unspecified