Provider Demographics
NPI:1871837468
Name:KIRIT S SHAH M.D., P.C.
Entity Type:Organization
Organization Name:KIRIT S SHAH M.D., P.C.
Other - Org Name:EAST PORTLAND UROLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:503-254-6418
Mailing Address - Street 1:171 NE 102ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4169
Mailing Address - Country:US
Mailing Address - Phone:503-254-6418
Mailing Address - Fax:503-254-1029
Practice Address - Street 1:171 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4169
Practice Address - Country:US
Practice Address - Phone:503-254-6418
Practice Address - Fax:503-254-1029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12620208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226662Medicaid
ORR0000BKZBRMedicare PIN
OR226662Medicaid