Healthcare Provider Details

I. General information

NPI: 1710305131
Provider Name (Legal Business Name): KAISER SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/22/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 EVERGREEN DR NE
GRAND RAPIDS MI
49525-9493
US

IV. Provider business mailing address

1107 WHITE PINE LN
WESTERN SPRINGS IL
60558-5018
US

V. Phone/Fax

Practice location:
  • Phone: 616-284-3132
  • Fax:
Mailing address:
  • Phone: 630-802-8747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301510705
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036147091
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: