Healthcare Provider Details

I. General information

NPI: 1205219516
Provider Name (Legal Business Name): ANUSHA GOPALKRISHNA SHANBHAG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2015
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 MEDICAL VILLAGE DRIVE
EDGEWOOD KY
41017-3439
US

IV. Provider business mailing address

P.O. BOX 636324
CINCINNATI OH
45263-6324
US

V. Phone/Fax

Practice location:
  • Phone: 859-287-3045
  • Fax: 859-578-3800
Mailing address:
  • Phone: 859-344-5555
  • Fax: 859-344-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01087807A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number56945
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: