MEDICARE: MITRA SHAMS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	TP723	KY
2	207R00000X	Internal Medicine Physician	40284	KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P00893048	OTHER	KY	RAILROAD MEDICARE - KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000699132	OTHER	KY	ANTHEM - NCMA
2	50031915	OTHER	KY	PASSPORT & PP ADVTG - NCMA
3	7659346	OTHER	KY	CIGNA - NCMA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	121562	OTHER	KY	SIHO - NCMA
8	000057058T	OTHER	KY	HUMANA - NCMA

General Provider Information

NPI Number	:	1043310329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITRA SHAMS MD

Provider Business Mailing Address
First Line	:	PO BOX 950248
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40295-0248
Country	:	US
Telephone Number	:	502-238-2801
Fax Number	:	502-238-2835

Provider Business Practice Location Address
First Line	:	6041 TIMBER RIDGE DR
Second Line	:
City	:	PROSPECT
State	:	KY
Zip	:	40059-8134
Country	:	US
Telephone Number	:	502-228-2225
Fax Number	:	502-228-2226

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	11/29/2012

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Directions to “ MITRA SHAMS MD” Practice Location

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