Healthcare Provider Details

I. General information

NPI: 1376821082
Provider Name (Legal Business Name): NEIL P SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 N 12TH ST
MILWAUKEE WI
53233
US

IV. Provider business mailing address

4025 N 92ND ST
WAUWATOSA WI
53222-1613
US

V. Phone/Fax

Practice location:
  • Phone: 414-358-5437
  • Fax: 414-358-5421
Mailing address:
  • Phone: 414-358-5437
  • Fax: 414-358-5421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number69712
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036144074
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number69712
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: