1174500664 NPI number — PRIYAMVADA N SHAH MD

Table of content: PRIYAMVADA N SHAH MD (NPI 1174500664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174500664 NPI number — PRIYAMVADA N SHAH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAH
Provider First Name:
PRIYAMVADA
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHAH
Provider Other First Name:
PRIYA
Provider Other Middle Name:
N
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1174500664
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8911 LIBERTY MILLS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804-6311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-373-9465
Provider Business Mailing Address Fax Number:
260-266-9406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8911 LIBERTY MILLS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-6311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-373-9465
Provider Business Practice Location Address Fax Number:
260-266-9406
Provider Enumeration Date:
12/27/2005

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: 207Q00000X , with the licence number:  01029161A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000111784 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0000002003211 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100051620 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1845 . This is a "PHYSICIANS HEALTH PLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 3937240003 . This is a "MEDICARE DMEPOS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 4052315 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 080130031 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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