MEDICARE: DR. SHELLY STYONS HARKINS MD

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	207Q00000X	Family Medicine Physician	036-107483	IL
2	207Q00000X	Family Medicine Physician	01076599A	IN
3	208M00000X	Hospitalist Physician	036.107483	IL
4	207QH0002X	Hospice and Palliative Medicine (Family Medicine) Physician	01076599A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922093871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHELLY STYONS HARKINS MD

Provider Business Mailing Address
First Line	:	710 N NILES AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-1924
Country	:	US
Telephone Number	:	574-647-1610
Fax Number	:	574-237-6069

Provider Business Practice Location Address
First Line	:	6913 N MAIN ST
Second Line	:
City	:	GRANGER
State	:	IN
Zip	:	46530-8039
Country	:	US
Telephone Number	:	574-647-1500
Fax Number	:	574-243-4310

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

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	11/07/2016

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Directions to “ DR. SHELLY STYONS HARKINS MD” Practice Location

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