=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104810027
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIKHIL S SHAH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2005
-----------------------------------------------------
Last Update Date | 04/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 780 CANTON RD NE STE 328
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060-7289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 943-610-0145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2106 OOLTEWAH RINGGOLD RD
-----------------------------------------------------
City | OOLTEWAH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37363-9345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-760-4360
-----------------------------------------------------
Fax | 423-760-4367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 36425
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 100040
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------