=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619331147
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIDDHARTH KIRIT SHAH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2016
-----------------------------------------------------
Last Update Date | 06/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6360 MABLETON PKWY SW
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-5210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-948-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6360 MABLETON PKWY SW
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-5210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-948-8600
-----------------------------------------------------
Fax | 770-944-7900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 82172
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------