Healthcare Provider Details

I. General information

NPI: 1609361948
Provider Name (Legal Business Name): FAIZAN SHAIKH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 06/04/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 2ND ST
BLOOMINGTON IN
47403-2317
US

IV. Provider business mailing address

601 W 2ND ST
BLOOMINGTON IN
47403-2317
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4102
  • Fax:
Mailing address:
  • Phone: 812-676-4102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351038773
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01085386A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: