Provider Demographics
NPI:1881733772
Name:AMIT I SHAH M D P A
Entity type:Organization
Organization Name:AMIT I SHAH M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-385-1244
Mailing Address - Street 1:4420 SUN N LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-2164
Mailing Address - Country:US
Mailing Address - Phone:863-385-1244
Mailing Address - Fax:863-385-6086
Practice Address - Street 1:4420 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-2164
Practice Address - Country:US
Practice Address - Phone:863-385-1244
Practice Address - Fax:863-385-6086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48069174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045758200Medicaid
FLD83969Medicare UPIN
FL045758200Medicaid
FL5391470001Medicare NSC