Provider Demographics
NPI:1760629307
Name:BADAL, SHAMIRAM (MD)
Entity Type:Individual
Prefix:
First Name:SHAMIRAM
Middle Name:
Last Name:BADAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:2930 W CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-6090
Practice Address - Country:US
Practice Address - Phone:574-335-8450
Practice Address - Fax:574-335-0760
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125053883390200000X
CAA113428207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000789617OtherBCBS
IL125053883OtherSTATE LICENSE
IN201073880Medicaid
IN01070305AOtherIN STATE ID
IN000000856561OtherBCBS NW
IN201073880Medicaid
INP01128630Medicare PIN
IN000000789617OtherBCBS
ININ2557100Medicare PIN