Provider Demographics
NPI:1417983537
Name:INTERNAL MEDICINE,GERIATRICS AND ONCOLOGY GROUP, P.C.
Entity Type:Organization
Organization Name:INTERNAL MEDICINE,GERIATRICS AND ONCOLOGY GROUP, P.C.
Other - Org Name:SHREYAS A. DESAI, M.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:G
Authorized Official - Last Name:NEUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-464-4786
Mailing Address - Street 1:2640 HAMSTROM RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3832
Mailing Address - Country:US
Mailing Address - Phone:219-762-9523
Mailing Address - Fax:219-763-3120
Practice Address - Street 1:2640 HAMSTROM RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3832
Practice Address - Country:US
Practice Address - Phone:219-762-9523
Practice Address - Fax:219-763-3120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027933A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200201230Medicaid
IN100157480AMedicaid
INC25010Medicare UPIN
IN100157480AMedicaid
IN234810AMedicare PIN