Healthcare Provider Details

I. General information

NPI: 1124090675
Provider Name (Legal Business Name): SARJU SHAH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15500 LUNDY PKWY
DEARBORN MI
48126-2778
US

IV. Provider business mailing address

42287 CHERRY HILL RD
CANTON MI
48188-1975
US

V. Phone/Fax

Practice location:
  • Phone: 313-586-5011
  • Fax: 313-792-7134
Mailing address:
  • Phone: 734-981-1086
  • Fax: 734-981-5094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301058742
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: