Healthcare Provider Details

I. General information

NPI: 1275728305
Provider Name (Legal Business Name): SHAH ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10640 HIGHWAY 21
HILLSBORO MO
63050
US

IV. Provider business mailing address

10640 BUSINESS 21 SUITE 5
HILLSBORO MO
63050-5039
US

V. Phone/Fax

Practice location:
  • Phone: 636-797-2330
  • Fax: 636-212-9200
Mailing address:
  • Phone: 636-797-2330
  • Fax: 636-212-9200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberMO104020
License Number StateMO

VIII. Authorized Official

Name: DR. SUDHIRKUMAR P SHAH
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 636-797-2330