=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801845839
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AAJAY N SHAH MD PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2006
-----------------------------------------------------
Last Update Date | 10/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2395 JOLLY RD SUITE 145
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-214-9119
-----------------------------------------------------
Fax | 517-574-5957
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2395 JOLLY RD SUITE 145
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-214-9119
-----------------------------------------------------
Fax | 517-574-5957
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. AAJAY N SHAH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 517-214-9119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 5601003722
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 4301055396
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 5601003787
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 4301055396
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------