Healthcare Provider Details

I. General information

NPI: 1942296157
Provider Name (Legal Business Name): GAUTAM K SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5454 HOHMAN AVE
HAMMOND IN
46320-1931
US

IV. Provider business mailing address

PO BOX 1000
DYER IN
46311-0800
US

V. Phone/Fax

Practice location:
  • Phone: 219-933-2270
  • Fax: 219-852-2515
Mailing address:
  • Phone: 219-864-2268
  • Fax: 219-864-2649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01029220A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: