Provider Demographics
NPI:1114903994
Name:AMIN, SHIRISH A (MD)
Entity Type:Individual
Prefix:
First Name:SHIRISH
Middle Name:A
Last Name:AMIN
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 1:1265 WAYNE AVE
Mailing Address - Street 2:119 PROFESSIONAL CENTER, SUITE 301
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3501
Mailing Address - Country:US
Mailing Address - Phone:724-465-6650
Mailing Address - Fax:724-357-9281
Practice Address - Street 1:1265 WAYNE AVE
Practice Address - Street 2:119 PROFESSIONAL CENTER, SUITE 301
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3501
Practice Address - Country:US
Practice Address - Phone:724-465-6650
Practice Address - Fax:724-357-9281
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050640L207RG0100X, 207RI0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00019110080002Medicaid
PA00019110080002Medicaid
PA056708Medicare ID - Type Unspecified