Provider Demographics
NPI:1033439989
Name:SHAH, RUSHABH ANILKUMAR (MD)
Entity Type:Individual
Prefix:
First Name:RUSHABH
Middle Name:ANILKUMAR
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1919 LAKE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7830
Practice Address - Country:US
Practice Address - Phone:574-948-5290
Practice Address - Fax:574-948-5495
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096224208000000X, 390200000X
IN01072555A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201166310Medicaid
IN000000821314OtherBCBS