=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871709295
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHIVU KAUSHIK M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 10/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11104 PARKVIEW CIRCLE DR STE 410
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-0025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-266-5260
-----------------------------------------------------
Fax | 260-667-2611
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11109 PARKVIEW PLAZA DR # 117
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-1701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-266-6013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 11355
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 0116016232
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 11355
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 11355
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 01079502A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------