Provider Demographics
NPI:1710305131
Name:SHAH, KAISER (MD)
Entity Type:Individual
Prefix:DR
First Name:KAISER
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 1:1107 WHITE PINE LN
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-5018
Mailing Address - Country:US
Mailing Address - Phone:630-802-8747
Mailing Address - Fax:
Practice Address - Street 1:3333 EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9493
Practice Address - Country:US
Practice Address - Phone:616-284-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301510705207L00000X
IL036147091207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology