Provider Demographics
NPI:1982668760
Name:SHAH, PIYUSH J (MD)
Entity Type:Individual
Prefix:DR
First Name:PIYUSH
Middle Name:J
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2814 THEATER AVE
Mailing Address - Street 2:PEDIATRIC MEDICAL GROUP INC
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-7978
Mailing Address - Country:US
Mailing Address - Phone:260-356-3611
Mailing Address - Fax:260-358-4263
Practice Address - Street 1:2814 THEATER AVE
Practice Address - Street 2:PEDIATRIC MEDICAL GROUP INC
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-7978
Practice Address - Country:US
Practice Address - Phone:260-356-3611
Practice Address - Fax:260-358-4263
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026608A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01026608AOtherLICENSE
IN100144900AMedicaid
INE03745Medicare UPIN
IN371220AMedicare ID - Type Unspecified