Healthcare Provider Details

I. General information

NPI: 1649440231
Provider Name (Legal Business Name): MUKUND R SHAH MD PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 HOLLYWOOD RD SUITE 102
SAINT JOSEPH MI
49085-8510
US

IV. Provider business mailing address

3800 HOLLYWOOD RD SUITE 102
SAINT JOSEPH MI
49085-8510
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-2727
  • Fax: 269-428-0377
Mailing address:
  • Phone: 269-428-2727
  • Fax: 269-428-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301039964
License Number StateMI

VIII. Authorized Official

Name: MUKUND R SHAH
Title or Position: OWNER
Credential: MD
Phone: 269-428-2727