Healthcare Provider Details

I. General information

NPI: 1932169968
Provider Name (Legal Business Name): GAURANG C SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 AMENDMENT AVE SUITE 102
ROCK HILL SC
29732-3036
US

IV. Provider business mailing address

165 AMENDMENT AVE SUITE 102
ROCK HILL SC
29732-3036
US

V. Phone/Fax

Practice location:
  • Phone: 803-329-2700
  • Fax: 803-329-2788
Mailing address:
  • Phone: 803-329-2700
  • Fax: 803-329-2788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22018
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: