Provider Demographics
NPI: | 1750670667 |
---|---|
Name: | SHAH, RENA (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | RENA |
Middle Name: | |
Last Name: | SHAH |
Suffix: | |
Gender: | F |
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: | 8170 33RD AVE S # MS 21110Q |
Mailing Address - Street 2: | |
Mailing Address - City: | BLOOMINGTON |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55425-4516 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 14000 FAIRVIEW DR |
Practice Address - Street 2: | |
Practice Address - City: | BURNSVILLE |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55337-5713 |
Practice Address - Country: | US |
Practice Address - Phone: | 952-883-8700 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-03-31 |
Last Update Date: | 2023-09-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WI | 60367 | 207R00000X |
MN | 63362 | 207RH0003X, 207RX0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RX0202X | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WI | 1750670667 | Medicaid |