MEDICARE: MRS. BHAIRAVI SAGAR SHAH RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	972682	NJ

General Provider Information

NPI Number	:	1154650190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BHAIRAVI SAGAR SHAH RD

Provider Business Mailing Address
First Line	:	PO BOX 178
Second Line	:
City	:	COLONIA
State	:	NJ
Zip	:	07067-0178
Country	:	US
Telephone Number	:	973-371-3166
Fax Number	:	973-371-3266

Provider Business Practice Location Address
First Line	:	40 UNION AVE STE 101
Second Line	:
City	:	IRVINGTON
State	:	NJ
Zip	:	07111-3290
Country	:	US
Telephone Number	:	973-371-3166
Fax Number	:	973-371-3266

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2009
Last Update Date	:	12/22/2009

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