Provider Demographics
NPI:1427385954
Name:BHANU J. SHAH MD PC
Entity Type:Organization
Organization Name:BHANU J. SHAH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BHANU
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-574-2190
Mailing Address - Street 1:29175 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092
Mailing Address - Country:US
Mailing Address - Phone:586-574-2190
Mailing Address - Fax:586-574-2203
Practice Address - Street 1:29175 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4243
Practice Address - Country:US
Practice Address - Phone:586-574-2190
Practice Address - Fax:586-574-2203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-04
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI31435207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0502020OtherBLUE CROSS AND BLUE SHIELD
MI1059764Medicaid
MI1059764Medicaid
MI0502020OtherBLUE CROSS AND BLUE SHIELD