Healthcare Provider Details

I. General information

NPI: 1821288788
Provider Name (Legal Business Name): POLLY WISHON-SHAH AS,RT,R,M,CT,MR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 07/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6451 N FEDERAL HWY SUITE 700
FT LAUDERDALE FL
33308-1402
US

IV. Provider business mailing address

7460B E SAINT CHARLES RD
COLUMBIA MO
65202-6801
US

V. Phone/Fax

Practice location:
  • Phone: 800-782-9029
  • Fax:
Mailing address:
  • Phone: 573-587-3426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number276262
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: