Healthcare Provider Details

I. General information

NPI: 1588667372
Provider Name (Legal Business Name): SUBHASH H SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S HILLSIDE ST STE A
WICHITA KS
67211-2151
US

IV. Provider business mailing address

220 S HILLSIDE ST STE A
WICHITA KS
67211-2151
US

V. Phone/Fax

Practice location:
  • Phone: 316-686-6866
  • Fax: 316-686-9797
Mailing address:
  • Phone: 316-686-6866
  • Fax: 316-686-9797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number04-24004
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number04-24004
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: