Provider Demographics
NPI:1508813338
Name:VASCULAR INSTITUTE OF SOUTHERN
Entity Type:Organization
Organization Name:VASCULAR INSTITUTE OF SOUTHERN
Other - Org Name:KENNETH J. SHAH, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-616-0500
Mailing Address - Street 1:2465 W HORIZON RIDGE PKWY
Mailing Address - Street 2:SUITE #100
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2649
Mailing Address - Country:US
Mailing Address - Phone:702-616-0500
Mailing Address - Fax:702-616-0505
Practice Address - Street 1:2465 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE #100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2649
Practice Address - Country:US
Practice Address - Phone:702-616-0500
Practice Address - Fax:702-616-0505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8591207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV33191Medicare PIN