Provider Demographics
NPI:1417963224
Name:SHIDHAM, GANESH B (MD)
Entity Type:Individual
Prefix:
First Name:GANESH
Middle Name:B
Last Name:SHIDHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-2594
Mailing Address - Fax:614-293-4487
Practice Address - Street 1:543 TAYLOR AVE FL 2
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-1278
Practice Address - Country:US
Practice Address - Phone:614-293-4837
Practice Address - Fax:614-293-3125
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2021-02-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35081621207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2347848Medicaid
OHH71672Medicare UPIN
OHSH4093742Medicare PIN