Basic Information
| Provider Information | |||||||||
| NPI: | 1558387217 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DAVE | ||||||||
| FirstName: | SHRUTI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 W. UNIVERSITY AVE | ||||||||
| Address2: | PROVIDER ENROLLMENT - NCW4 | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 7403958592 | ||||||||
| Practice Location | |||||||||
| Address1: | 1813 W. KIRBY AVENUE | ||||||||
| Address2: | ENDOCRINOLOGY | ||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173833490 | ||||||||
| FaxNumber: | 2173833439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 06/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 35084113 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 7030597 | 01 | OH | AETNA | OTHER | 000000349199 | 01 | OH | ANTHEM | OTHER | 2503973 | 05 | OH | MEDICAID |