Provider Demographics
NPI:1871876458
Name:SHANTHARAM SHETTY, MD MED PRO CORP,
Entity type:Organization
Organization Name:SHANTHARAM SHETTY, MD MED PRO CORP,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANTHARAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-949-9918
Mailing Address - Street 1:1964 STATE ST STE 206
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-4992
Mailing Address - Country:US
Mailing Address - Phone:812-949-9918
Mailing Address - Fax:812-949-9918
Practice Address - Street 1:1964 STATE ST STE 206
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4992
Practice Address - Country:US
Practice Address - Phone:812-949-9918
Practice Address - Fax:812-949-9918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031319A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100075510Medicaid
IN100075510Medicaid