Healthcare Provider Details

I. General information

NPI: 1265082697
Provider Name (Legal Business Name): SHEM CARLO BANDA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 MISSOURI AVE
JEFFERSONVILLE IN
47130-3725
US

IV. Provider business mailing address

1808 HERR LN
LOUISVILLE KY
40222-6556
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-6631
  • Fax:
Mailing address:
  • Phone: 480-273-5015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number10002804A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: