Provider Demographics
NPI:1528088689
Name:SHAH, SURENDRA J (MD)
Entity type:Individual
Prefix:DR
First Name:SURENDRA
Middle Name:J
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5825 BROADWAY STE A
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-2664
Mailing Address - Country:US
Mailing Address - Phone:219-884-1400
Mailing Address - Fax:219-884-1453
Practice Address - Street 1:5825 BROADWAY
Practice Address - Street 2:SUITE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2687
Practice Address - Country:US
Practice Address - Phone:219-884-1400
Practice Address - Fax:219-884-1453
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032180207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100169840AMedicaid
IN100169840AMedicaid
IN499810AMedicare PIN