Provider Demographics
NPI:1740288323
Name:SHAH, AMIT G (MD)
Entity type:Individual
Prefix:
First Name:AMIT
Middle Name:G
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1040 EDGEWATER CORP PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-4514
Mailing Address - Country:US
Mailing Address - Phone:803-548-7007
Mailing Address - Fax:803-802-2015
Practice Address - Street 1:1040 EDGEWATER CORP PKWY STE 101
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-4514
Practice Address - Country:US
Practice Address - Phone:803-548-7007
Practice Address - Fax:803-802-2015
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC20170207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT42040Medicaid
SCG74375Medicare UPIN
SCG743755986Medicare ID - Type Unspecified