Provider Demographics
NPI:1417318635
Name:SHALOM MEDICAL INC
Entity Type:Organization
Organization Name:SHALOM MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADETUJNI
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEJUMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-530-8357
Mailing Address - Street 1:977 GREEN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:977 GREEN RIDGE DR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7656
Practice Address - Country:US
Practice Address - Phone:718-530-8357
Practice Address - Fax:920-328-9050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty