Provider Demographics
NPI:1578720702
Name:GREATHOUSE, SHAWN TRAVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:TRAVIS
Last Name:GREATHOUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-962-4872
Mailing Address - Fax:765-935-8913
Practice Address - Street 1:1911 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1212
Practice Address - Country:US
Practice Address - Phone:765-962-4872
Practice Address - Fax:765-935-8913
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073741A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000951920OtherANTHEM
IN201241270Medicaid
IN201241270Medicaid