Provider Demographics
NPI:1821409319
Name:SHAH, PHALGOON A (MD)
Entity type:Individual
Prefix:DR
First Name:PHALGOON
Middle Name:A
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 1:1 MEDICAL VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3403
Mailing Address - Country:US
Mailing Address - Phone:859-757-2927
Mailing Address - Fax:859-341-0203
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-757-2927
Practice Address - Fax:859-341-0203
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY53445207RP1001X, 207RC0200X
CODR.0065750207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO029220OtherKAISER COMMERCIAL NUMBER
KY7100660020Medicaid