Basic Information
| Provider Information | |||||||||
| NPI: | 1669634770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FADIA | ||||||||
| FirstName: | SHRUTI | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M,D, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 NAVARRE PL | ||||||||
| Address2: | SUITE 5550 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746472550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MT192950 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 01074405A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0205X | 01074405A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 201247820 | 05 | IN | MEDICAID |