MEDICARE: SHAILI SANJAY KOTHARI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207R00000X	Internal Medicine Physician	MD485678	PA

General Provider Information

NPI Number	:	1013594126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAILI SANJAY KOTHARI

Provider Business Mailing Address
First Line	:	100 N ACADEMY AVE
Second Line	:
City	:	DANVILLE
State	:	PA
Zip	:	17822-1304
Country	:	US
Telephone Number	:	570-214-9208
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 N ACADEMY AVE
Second Line	:
City	:	DANVILLE
State	:	PA
Zip	:	17822-1304
Country	:	US
Telephone Number	:	570-214-9208
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2021
Last Update Date	:	06/17/2025

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