Healthcare Provider Details

I. General information

NPI: 1396959136
Provider Name (Legal Business Name): COLON, RECTAL AND LASER SURGERY ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5705 MONCLOVA RD SUITE 203
MAUMEE OH
43537-1875
US

IV. Provider business mailing address

5705 MONCLOVA RD SUITE 203
MAUMEE OH
43537-1875
US

V. Phone/Fax

Practice location:
  • Phone: 419-893-2622
  • Fax: 419-893-2755
Mailing address:
  • Phone: 419-893-2622
  • Fax: 419-893-2755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RAJU S SHAH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 419-893-2622