=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790137685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAH FOOT & ANKLE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2016
-----------------------------------------------------
Last Update Date | 07/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3851 N MULFORD RD
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61114-5603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-254-5939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3851 N MULFORD RD
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61114-5603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-254-5939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / CEO
-----------------------------------------------------
Name | DR. BIREN SHAH
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 847-254-5939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 016.005692
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------