Healthcare Provider Details

I. General information

NPI: 1811985062
Provider Name (Legal Business Name): GREGORY ERNEST SHADID MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 LEEPER AVE
SOUTH BEND IN
46617-1209
US

IV. Provider business mailing address

1213 LEEPER AVE
SOUTH BEND IN
46617-1209
US

V. Phone/Fax

Practice location:
  • Phone: 574-302-8786
  • Fax: 405-310-4417
Mailing address:
  • Phone: 574-302-8786
  • Fax: 405-310-4417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01082994A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOK20542
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberK1056
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: