Provider Demographics
NPI:1245797208
Name:SHAZE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SHAZE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SYED
Authorized Official - Middle Name:Q
Authorized Official - Last Name:KAZMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-282-2218
Mailing Address - Street 1:1035 WALL STREET STE 104-C1
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3602
Mailing Address - Country:US
Mailing Address - Phone:812-282-2218
Mailing Address - Fax:812-282-2252
Practice Address - Street 1:1035 WALL STREET STE 104-C1
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3602
Practice Address - Country:US
Practice Address - Phone:812-282-2218
Practice Address - Fax:812-282-2252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-26
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300023539Medicaid