Healthcare Provider Details

I. General information

NPI: 1164326062
Provider Name (Legal Business Name): GOLIAN PROCTOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5534 SAINT JOE RD
FORT WAYNE IN
46835-3328
US

IV. Provider business mailing address

5534 SAINT JOE RD
FORT WAYNE IN
46835-3328
US

V. Phone/Fax

Practice location:
  • Phone: 317-645-5120
  • Fax:
Mailing address:
  • Phone: 317-645-5120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. SHIVA GOLIAN
Title or Position: PHYSICIAN
Credential: DO
Phone: 317-645-5120