Provider Demographics
NPI:1699112052
Name:SHIVAM MEDICAL GROUP, PA
Entity type:Organization
Organization Name:SHIVAM MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:NISHI
Authorized Official - Middle Name:
Authorized Official - Last Name:THAKUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-910-5550
Mailing Address - Street 1:8518 CULEBRA ROAD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251
Mailing Address - Country:US
Mailing Address - Phone:210-910-5550
Mailing Address - Fax:210-971-9077
Practice Address - Street 1:8518 CULEBRA ROAD
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251
Practice Address - Country:US
Practice Address - Phone:210-910-5550
Practice Address - Fax:210-971-9077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2392261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center