Provider Demographics
NPI:1841278066
Name:MENON, SHAJI C (MD)
Entity type:Individual
Prefix:DR
First Name:SHAJI
Middle Name:C
Last Name:MENON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1000 NORTH FRONT STREET
Mailing Address - Street 2:SUITE 290 PEDIATRIC CARDIOLOGY
Mailing Address - City:WORMLEYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17043-1045
Mailing Address - Country:US
Mailing Address - Phone:717-761-0200
Mailing Address - Fax:717-761-0641
Practice Address - Street 1:1000 NORTH FRONT STREET
Practice Address - Street 2:SUITE 290 PEDIATRIC CARDIOLOGY
Practice Address - City:WORMLEYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17043-1045
Practice Address - Country:US
Practice Address - Phone:717-761-0200
Practice Address - Fax:717-761-0641
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD476839208000000X, 2080P0202X
UT6962746-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
I44405Medicare UPIN
MN370003080Medicare ID - Type Unspecified