Provider Demographics
NPI:1134120603
Name:SHAH, RAMESH R (MD, FACS,)
Entity Type:Individual
Prefix:DR
First Name:RAMESH
Middle Name:R
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD, FACS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 W 30TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1603
Mailing Address - Country:US
Mailing Address - Phone:417-781-2616
Mailing Address - Fax:417-781-2934
Practice Address - Street 1:1703 W 30TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1603
Practice Address - Country:US
Practice Address - Phone:417-781-2616
Practice Address - Fax:417-781-2934
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2014-09-30
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
MOR1-D43174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100004110AMedicaid
KS070280OtherBCBS OF KS
MO124365OtherHEALTHLINK
MO201842408Medicaid
MO201842416Medicaid
MO27777OtherBCBS OF MO
KS070280OtherBCBS OF KS
MO27777OtherBCBS OF MO
OK100004110AMedicaid