Healthcare Provider Details

I. General information

NPI: 1104177179
Provider Name (Legal Business Name): SHIRALI SHAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2012
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 AUDUBON PLAZA DR
LOUISVILLE KY
40217-1318
US

IV. Provider business mailing address

PO BOX 36218
LOUISVILLE KY
40233-6218
US

V. Phone/Fax

Practice location:
  • Phone: 502-634-6767
  • Fax: 502-634-6775
Mailing address:
  • Phone: 502-634-6767
  • Fax: 502-634-6775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberTP495
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT202590
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberIP1398
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR3680
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number49804
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: