Basic Information
| Provider Information | |||||||||
| NPI: | 1902903701 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAYESTEH | ||||||||
| FirstName: | AMID | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 REID PARKWAY | ||||||||
| Address2: | MEDICAL STAFF SERVICES | ||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473741157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659358807 | ||||||||
| FaxNumber: | 7659833219 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 REID PARKWAY | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473741157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659833144 | ||||||||
| FaxNumber: | 7659833038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 05/06/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 02001165A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000031530 | 01 | IN | BLUE SHIELD - REID HOSP | OTHER | 085200 | 05 | OH | MEDICAID | 100367840 | 05 | IN | MEDICAID |