Provider Demographics
NPI:1366420366
Name:SHAHWAN, TOM G (MD)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:G
Last Name:SHAHWAN
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 1:601 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-1954
Mailing Address - Fax:269-341-8314
Practice Address - Street 1:601 JOHN ST STE M-124
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5377
Practice Address - Country:US
Practice Address - Phone:269-341-7500
Practice Address - Fax:269-341-8314
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301101812208100000X
MN47773207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN407170100Medicaid
I36626Medicare UPIN
MN200002352Medicare ID - Type Unspecified