=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164698395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAH PEDIATRICS,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2008
-----------------------------------------------------
Last Update Date | 05/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 PHILIP BLVD
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30045-8700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-962-3141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 PHILIP BLVD
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30045-8700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-962-3141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRIC DOCTOR
-----------------------------------------------------
Name | DR. TARU N SHAH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-962-3141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------