Provider Demographics
NPI:1831166073
Name:FALLOON, SHEILA (MD)
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:FALLOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHEILA
Other - Middle Name:
Other - Last Name:KONGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7916 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-434-6377
Mailing Address - Fax:260-434-6389
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-434-7088
Practice Address - Fax:260-435-7394
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043979208M00000X
IN01043979A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200515420Medicaid
IN000000363549OtherANTHEM
IN000000363549OtherANTHEM
INMI8546001Medicare PIN
F54171Medicare UPIN
P00238484OtherRAILROAD
IN058490KKKMedicare ID - Type Unspecified