Provider Demographics
NPI:1922093871
Name:HARKINS, SHELLY STYONS (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:STYONS
Last Name:HARKINS
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:6913 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8039
Practice Address - Country:US
Practice Address - Phone:574-647-1500
Practice Address - Fax:574-243-4310
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107483207Q00000X
IN01076599A207Q00000X, 207QH0002X
IL036.107483208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201394170Medicaid
ILOTH000Medicare UPIN
IN201394170Medicaid