=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407850449
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMIT INDRAVADAN SHAH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2005
-----------------------------------------------------
Last Update Date | 09/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1396 WHISPER CIR
-----------------------------------------------------
City | SEBRING
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33870-1204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-385-1244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 102222 ATTN: CREDENTIAL DEPARTMENT
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30368-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-274-8200
-----------------------------------------------------
Fax | 239-278-3350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0000X
-----------------------------------------------------
Taxonomy Name | Hematology (Internal Medicine) Physician
-----------------------------------------------------
License Number | ME48069
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number | ME48069
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------