Provider Demographics
NPI:1134449192
Name:HARRUNA, SHAYIBU (MD)
Entity type:Individual
Prefix:DR
First Name:SHAYIBU
Middle Name:
Last Name:HARRUNA
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 1239
Mailing Address - Street 2:6500 HOSPITAL DRIVE
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-1239
Mailing Address - Country:US
Mailing Address - Phone:573-629-3300
Mailing Address - Fax:573-629-3314
Practice Address - Street 1:6500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6890
Practice Address - Country:US
Practice Address - Phone:573-629-3300
Practice Address - Fax:573-629-3314
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016030318207RI0011X
AZ43218207RC0000X
LAMD.204554207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05513481Medicaid
LA2153447Medicaid
LA2153447Medicaid
WYW25610Medicare PIN