Healthcare Provider Details

I. General information

NPI: 1033104948
Provider Name (Legal Business Name): BALU B SHETTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8775 NORWIN AVE SUITE 113
N HUNTINGDON PA
15642-2718
US

IV. Provider business mailing address

585 RUGH ST
GREENSBURG PA
15601-5667
US

V. Phone/Fax

Practice location:
  • Phone: 724-864-0503
  • Fax: 724-864-0535
Mailing address:
  • Phone: 724-838-1534
  • Fax: 724-838-1536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD039618L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: