Healthcare Provider Details

I. General information

NPI: 1487742896
Provider Name (Legal Business Name): SYED MUHAMMAD SHAN UL ISLAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 JOE FRANK HARRIS PKWY SE
CARTERSVILLE GA
30120-2129
US

IV. Provider business mailing address

2022 KELLE DR
CHESTERTON IN
46304-8708
US

V. Phone/Fax

Practice location:
  • Phone: 470-490-2142
  • Fax:
Mailing address:
  • Phone: 219-364-4004
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number85117
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01070169A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number19490
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number85117
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: