Basic Information
| Provider Information | |||||||||
| NPI: | 1871542324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAIN | ||||||||
| FirstName: | SHASHI | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 385 | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440520385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008414236 | ||||||||
| FaxNumber: | 7066530615 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 E RIVER ST | ||||||||
| Address2: | 4TH FLOOR PATH DEPT | ||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440355902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403297656 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 35069279 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 2224131 | 05 | OH | MEDICAID |