Provider Demographics
NPI:1932158136
Name:SHANAVAS, THARACKANDATHIL OORAN (MD)
Entity Type:Individual
Prefix:
First Name:THARACKANDATHIL
Middle Name:OORAN
Last Name:SHANAVAS
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 1:901 KIMOLE LN
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1491
Mailing Address - Country:US
Mailing Address - Phone:517-263-6733
Mailing Address - Fax:517-263-7148
Practice Address - Street 1:901 KIMOLE LN
Practice Address - Street 2:SUITE B-1
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1491
Practice Address - Country:US
Practice Address - Phone:517-263-6733
Practice Address - Fax:517-263-7148
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITS034422208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI350D676100OtherBLUE CROSS AND BLUE SHIEL
MI18632OtherHEALTH PLAN OF MI
MI5450691OtherAETNA
MI03744OtherPARAMOUNT
MI1099349Medicaid
MI115715OtherCARE CHOICE
MI119775OtherGREAT LAKES OF MI
MIA79803Medicare UPIN