Healthcare Provider Details

I. General information

NPI: 1861329070
Provider Name (Legal Business Name): SHIVESH SHAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2689
US

IV. Provider business mailing address

8 ELLERY LN
BURLINGTON MA
01803-1851
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2600
  • Fax:
Mailing address:
  • Phone: 978-979-1969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351056400
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: