=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760997381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAMZA W SHAH DO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2017
-----------------------------------------------------
Last Update Date | 03/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 MACCORKLE AVE SE STE 509
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-1226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-342-0821
-----------------------------------------------------
Fax | 304-345-6679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 MACCORKLE AVE SE STE 509
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-1226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-342-0821
-----------------------------------------------------
Fax | 304-345-6679
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HAMZA W. SHAH
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 304-342-0821
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 3176
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------