Provider Demographics
NPI:1235349929
Name:SHAH MEDICAL GROUP APMC
Entity Type:Organization
Organization Name:SHAH MEDICAL GROUP APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MRUNALINI
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-671-1745
Mailing Address - Street 1:PO BOX 3591
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71133-3591
Mailing Address - Country:US
Mailing Address - Phone:318-671-1745
Mailing Address - Fax:
Practice Address - Street 1:5607 MIRADOR CIR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-4009
Practice Address - Country:US
Practice Address - Phone:318-671-1745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL40598R208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CJ31Medicare ID - Type Unspecified