Provider Demographics
NPI:1649440231
Name:MUKUND R SHAH MD PLC
Entity type:Organization
Organization Name:MUKUND R SHAH MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MUKUND
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-428-2727
Mailing Address - Street 1:3800 HOLLYWOOD RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8510
Mailing Address - Country:US
Mailing Address - Phone:269-428-2727
Mailing Address - Fax:269-428-0377
Practice Address - Street 1:3800 HOLLYWOOD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8510
Practice Address - Country:US
Practice Address - Phone:269-428-2727
Practice Address - Fax:269-428-0377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039964208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty