Healthcare Provider Details

I. General information

NPI: 1144640061
Provider Name (Legal Business Name): SHIVAM SHAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

IV. Provider business mailing address

PO BOX 678678
DALLAS TX
75267-8678
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-1596
  • Fax: 610-889-0813
Mailing address:
  • Phone: 800-475-6112
  • Fax: 423-826-1286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD472121
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD472121
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: