Provider Demographics
NPI:1184659971
Name:SHAH, SYED JIRGIS (MD)
Entity Type:Individual
Prefix:
First Name:SYED
Middle Name:JIRGIS
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 1:2845 GREENBRIER RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6519
Mailing Address - Country:US
Mailing Address - Phone:920-288-8100
Mailing Address - Fax:920-288-8145
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8100
Practice Address - Fax:920-288-8145
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50775207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34934100Medicaid
WI004771460Medicare PIN
WI34934100Medicaid
WI026007650Medicare PIN