Provider Demographics
NPI:1306879606
Name:KOURY, SHAHEED (MD)
Entity type:Individual
Prefix:
First Name:SHAHEED
Middle Name:
Last Name:KOURY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10623 MONTE VISTA CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9069
Mailing Address - Country:US
Mailing Address - Phone:260-625-5341
Mailing Address - Fax:
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056850207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN142520WMedicare ID - Type Unspecified
IN138420HHHMedicare ID - Type Unspecified
IN295910ZZZMedicare ID - Type Unspecified
IN178650UMedicare ID - Type Unspecified
INF74194Medicare UPIN