1487742896 NPI number — SYED MUHAMMAD SHAN UL ISLAM MD

Table of content: SYED MUHAMMAD SHAN UL ISLAM MD (NPI 1487742896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487742896 NPI number — SYED MUHAMMAD SHAN UL ISLAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAN UL ISLAM
Provider First Name:
SYED
Provider Middle Name:
MUHAMMAD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487742896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2022 KELLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46304-8708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-364-4004
Provider Business Mailing Address Fax Number:
219-326-2584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1331 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PORTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46350-3112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-326-1775
Provider Business Practice Location Address Fax Number:
219-326-1951
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  19490 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 01070169A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05388729 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: M400055273 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 151020025 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P01003687 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201034600 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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