Provider Demographics
NPI:1194816397
Name:SHAH MEDICAL GROUP LLP
Entity Type:Organization
Organization Name:SHAH MEDICAL GROUP LLP
Other - Org Name:SURENDRA AND MRUDULA SHAH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SURENDRALAL
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-822-4706
Mailing Address - Street 1:528 OLD COUNTRY ROAD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4997
Mailing Address - Country:US
Mailing Address - Phone:516-822-4706
Mailing Address - Fax:516-822-1373
Practice Address - Street 1:528 OLD COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4997
Practice Address - Country:US
Practice Address - Phone:516-822-4706
Practice Address - Fax:516-822-1373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144360207R00000X
NY133617207R00000X, 207RN0300X
NY143360207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW19081Medicare PIN