Provider Demographics
NPI:1184663627
Name:SHAH, JAYESH R (MD)
Entity type:Individual
Prefix:
First Name:JAYESH
Middle Name:R
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 1:2000 GREEN RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 E POTTAWATAMIE ST
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-2018
Practice Address - Country:US
Practice Address - Phone:517-423-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI084511207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4718360Medicaid
MI4685027Medicaid
MIJS084511OtherBC/BS
MIJS084511OtherBC/BS
MIA82630Medicare UPIN
MIM60660290Medicare PIN