Healthcare Provider Details

I. General information

NPI: 1760656706
Provider Name (Legal Business Name): GAURANG SURENDRA SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 BEAM AVE
MAPLEWOOD MN
55109-1126
US

IV. Provider business mailing address

10700 HAWTHORN TRL
WOODBURY MN
55129-8767
US

V. Phone/Fax

Practice location:
  • Phone: 651-326-7200
  • Fax:
Mailing address:
  • Phone: 651-815-0314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number51638
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: