Healthcare Provider Details

I. General information

NPI: 1659590792
Provider Name (Legal Business Name): TANMAYA C SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 06/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CARNIE BLVD SUITE B-5
VOORHEES NJ
08043-4512
US

IV. Provider business mailing address

PO BOX 1710
VOORHEES NJ
08043-7710
US

V. Phone/Fax

Practice location:
  • Phone: 856-374-4031
  • Fax:
Mailing address:
  • Phone: 856-770-0504
  • Fax: 856-770-0395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number231272
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: