Provider Demographics
NPI:1659425817
Name:PENDEM, SHANTHAN (MD)
Entity Type:Individual
Prefix:
First Name:SHANTHAN
Middle Name:
Last Name:PENDEM
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:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:1400 RIVER PL
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5600
Practice Address - Country:US
Practice Address - Phone:770-848-8000
Practice Address - Fax:770-848-8601
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9882207R00000X
GA68271207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDP00256319OtherRR MEDICARE
ND13617Medicaid
NDH88349Medicare UPIN
NDP00256319OtherRR MEDICARE