Healthcare Provider Details

I. General information

NPI: 1487974663
Provider Name (Legal Business Name): JAY SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S CENTER ST
HARTFORD MI
49057-1362
US

IV. Provider business mailing address

525 S CENTER ST
HARTFORD MI
49057-1362
US

V. Phone/Fax

Practice location:
  • Phone: 269-463-3600
  • Fax: 269-621-9972
Mailing address:
  • Phone: 269-463-3600
  • Fax: 269-621-9972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036133075
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301103258
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: