Healthcare Provider Details

I. General information

NPI: 1841306693
Provider Name (Legal Business Name): KETAN SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ELEVEN S STE 4F
COLUMBIA IL
62236-1080
US

IV. Provider business mailing address

1000 ELEVEN S STE 4F
COLUMBIA IL
62236-1080
US

V. Phone/Fax

Practice location:
  • Phone: 618-628-0715
  • Fax: 888-371-4468
Mailing address:
  • Phone: 618-628-0715
  • Fax: 888-371-4468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036-101869
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: