Healthcare Provider Details

I. General information

NPI: 1750886834
Provider Name (Legal Business Name): VISHAL UMED SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 82ND PARKWAY GME OFFICE
MYRTLE BEACH SC
29572
US

IV. Provider business mailing address

809 82ND PARKWAY GME OFFICE
MYRTLE BEACH SC
29572
US

V. Phone/Fax

Practice location:
  • Phone: 843-692-1752
  • Fax: 843-692-1904
Mailing address:
  • Phone: 843-692-1752
  • Fax: 843-692-1904

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 State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101272101
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: