Healthcare Provider Details

I. General information

NPI: 1780021451
Provider Name (Legal Business Name): MOUSUMEE SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PLZ
DAYTON OH
45404-1815
US

IV. Provider business mailing address

PO BOX 933432
CLEVELAND OH
44193-0039
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-3000
  • Fax: 937-641-3107
Mailing address:
  • Phone: 937-641-5072
  • Fax: 919-843-7036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number192323
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number192323
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number35.137318
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: