Basic Information
| Provider Information | |||||||||
| NPI: | 1376860890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | HAIDER | ||||||||
| MiddleName: | RAZA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 E COUNTY LINE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461431070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178852860 | ||||||||
| FaxNumber: | 3178852869 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 E COUNTY LINE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461431072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178852860 | ||||||||
| FaxNumber: | 3178852869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2010 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01068115A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 01068115A | IN | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 200985130 | 05 | IN | MEDICAID |