Healthcare Provider Details

I. General information

NPI: 1619914140
Provider Name (Legal Business Name): YAHYA EL-SHINNAWY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W WESTERN AVE
SOUTH BEND IN
46619-3569
US

IV. Provider business mailing address

8003 CASTLEWAY DR
INDIANAPOLIS IN
46250-1946
US

V. Phone/Fax

Practice location:
  • Phone: 317-576-1335
  • Fax:
Mailing address:
  • Phone: 317-576-1335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number38125
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: