Provider Demographics
NPI:1679684872
Name:SHAH, BASIL (MD)
Entity Type:Individual
Prefix:
First Name:BASIL
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-867-5006
Mailing Address - Fax:228-867-5079
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-867-5006
Practice Address - Fax:228-867-5079
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077845174400000X
MS227742085R0204X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No174400000XOther Service ProvidersSpecialist
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA107229OtherAL MEDICAID
00188398OtherMS MEDICAID