Provider Demographics
NPI:1164660866
Name:KALIM, SHADAB
Entity Type:Individual
Prefix:
First Name:SHADAB
Middle Name:
Last Name:KALIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SHENANGO AVE
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146-1503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 12TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-3100
Practice Address - Country:US
Practice Address - Phone:814-942-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD443337207RG0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102650858Medicaid
PA102650858Medicaid