Provider Demographics
NPI:1275579906
Name:RUPA K. SHAH, MD, PC
Entity Type:Organization
Organization Name:RUPA K. SHAH, MD, PC
Other - Org Name:CLACKAMAS PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPANY PRESIDENT MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUPA
Authorized Official - Middle Name:KIRIT
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-659-1694
Mailing Address - Street 1:8645 SE SUNNYBROOK BLVD #200
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6841
Mailing Address - Country:US
Mailing Address - Phone:503-659-1694
Mailing Address - Fax:503-659-8984
Practice Address - Street 1:8645 SE SUNNYBROOK BLVD #200
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6841
Practice Address - Country:US
Practice Address - Phone:503-659-1694
Practice Address - Fax:503-659-8984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287686Medicaid