1104889484 NPI number — JAY H AND VIJAYA J SHAH MD

Table of content: (NPI 1104889484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104889484 NPI number — JAY H AND VIJAYA J SHAH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAY H AND VIJAYA J SHAH MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1104889484
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
862 SECOND STREET PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHBORO
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18954-1005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-322-9292
Provider Business Mailing Address Fax Number:
215-322-4394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2562 KNIGHTS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENSALEM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19020-3400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-244-6363
Provider Business Practice Location Address Fax Number:
215-244-6365
Provider Enumeration Date:
04/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
JAY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PHYSICIAN-OWNER
Authorized Official Telephone Number:
215-322-9292

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0010343440006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0423947002 . This is a "IBC-HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0008385670005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1017977 . This is a "KEY STONE MERCY-PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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