Healthcare Provider Details

I. General information

NPI: 1831327097
Provider Name (Legal Business Name): SURAJ PRAVIN SHAH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 08/07/2022
Certification Date: 08/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 S MAIN ST
HOLLY SPRINGS NC
27540-8906
US

IV. Provider business mailing address

PO BOX 2705
HUNTSVILLE AL
35804-2705
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-7093
  • Fax:
Mailing address:
  • Phone: 256-265-3880
  • Fax: 256-265-3886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number31873
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2018-00078
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2018-00078
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: