Basic Information
| Provider Information | |||||||||
| NPI: | 1336140441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAS | ||||||||
| FirstName: | SHILPI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 OGLETHORPE AVE | ||||||||
| Address2: | SUITE 600F | ||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306062179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064754639 | ||||||||
| FaxNumber: | 7064754636 | ||||||||
| Practice Location | |||||||||
| Address1: | 1199 PRINCE AVE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306062797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064757000 | ||||||||
| FaxNumber: | 7064757684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 060447 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 060447 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01YP05102NH02 | 01 | NH | ANTHEM BC/BS | OTHER | 5830418 | 01 | AETNA GROUP | OTHER | P00100688 | 01 | RAILROAD MEDICARE | OTHER | 11867 | 01 | NH | STATE LICENSE # | OTHER | 2184240001 | 01 | NH | CIGNA HEALTHCARE | OTHER | BD8289642 | 01 | DEA # | OTHER | 020350051 | 01 | FEDERAL TAX ID | OTHER | 30204719 | 05 | NH | MEDICAID |