Healthcare Provider Details

I. General information

NPI: 1972766368
Provider Name (Legal Business Name): TINA SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 BROADWAY BLVD
KANSAS CITY MO
64111-3315
US

IV. Provider business mailing address

4440 BROADWAY BLVD
KANSAS CITY MO
64111-3315
US

V. Phone/Fax

Practice location:
  • Phone: 703-751-8804
  • Fax: 703-751-1218
Mailing address:
  • Phone: 703-751-8804
  • Fax: 703-751-1218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101247807
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD038290
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD038290
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: