Provider Demographics
NPI:1679575021
Name:JOHN, SHIRLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHIRLEY
Other - Middle Name:JOHN
Other - Last Name:KAITHACKACHALIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 NEW SALEM ROAD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401
Mailing Address - Country:US
Mailing Address - Phone:724-437-0729
Mailing Address - Fax:724-437-2761
Practice Address - Street 1:100 NEW SALEM ROAD
Practice Address - Street 2:SUITE 116
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401
Practice Address - Country:US
Practice Address - Phone:724-437-0729
Practice Address - Fax:724-437-2761
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD068587L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2316014Medicaid
WV3810001565Medicaid
PA0017665890005Medicaid
OH2316014Medicaid