Provider Demographics
NPI:1437338829
Name:SURENDRA J SHAH PC
Entity Type:Organization
Organization Name:SURENDRA J SHAH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SURENDRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-884-1400
Mailing Address - Street 1:5825 BROADWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-2687
Mailing Address - Country:US
Mailing Address - Phone:219-884-1400
Mailing Address - Fax:219-884-1453
Practice Address - Street 1:5825 BROADWAY
Practice Address - Street 2:SUITE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2687
Practice Address - Country:US
Practice Address - Phone:219-884-1400
Practice Address - Fax:219-884-1453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032180A207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
499810Medicare PIN
INC25258Medicare UPIN