1154376713 NPI number — CHANDRAKANT C SHAH MD

Table of content: CHANDRAKANT C SHAH MD (NPI 1154376713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154376713 NPI number — CHANDRAKANT C SHAH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAH
Provider First Name:
CHANDRAKANT
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154376713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 N WALNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOYERTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19512-1467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-369-0913
Provider Business Mailing Address Fax Number:
610-369-0917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 WALNUT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOYERTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19512-1300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-369-0913
Provider Business Practice Location Address Fax Number:
610-367-8418
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD038812L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000406783 . This is a "HIGHMARK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01227301 . This is a "CBC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0015083320001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0007687760006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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