MEDICARE: DR. YOGENDRA AMBALAL SHAH M.D.,S.C.

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	174400000X	Specialist	036048989	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376667253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. YOGENDRA AMBALAL SHAH M.D.,S.C.

Provider Business Mailing Address
First Line	:	3165 MYRTLE AVE
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-5012
Country	:	US
Telephone Number	:	618-451-7717
Fax Number	:	618-451-7780

Provider Business Practice Location Address
First Line	:	3165 MYRTLE AVE
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-5012
Country	:	US
Telephone Number	:	618-451-7717
Fax Number	:	618-451-7780

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

Provider Enumeration Date	:	03/18/2007
Last Update Date	:	07/08/2007

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