=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295017085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UTICA SHELBY URGENT CARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2011
-----------------------------------------------------
Last Update Date | 09/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45569 VAN DYKE AVE STE 3
-----------------------------------------------------
City | UTICA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48317-5617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-258-8791
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45569 VAN DYKE AVE STE 3
-----------------------------------------------------
City | UTICA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48317-5617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-258-8791
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KUNJESH P SHAH
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 586-258-8791
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | 4301090856
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------