MEDICARE: VASCULAR INSTITUTE OF SOUTHERN

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	207RC0000X	Cardiovascular Disease Physician	8591	NV

General Provider Information

NPI Number	:	1508813338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VASCULAR INSTITUTE OF SOUTHERN

Provider Business Mailing Address
First Line	:	2465 W HORIZON RIDGE PKWY
Second Line	:	SUITE #100
City	:	HENDERSON
State	:	NV
Zip	:	89052-2649
Country	:	US
Telephone Number	:	702-616-0500
Fax Number	:	702-616-0505

Provider Business Practice Location Address
First Line	:	2465 W HORIZON RIDGE PKWY
Second Line	:	SUITE #100
City	:	HENDERSON
State	:	NV
Zip	:	89052-2649
Country	:	US
Telephone Number	:	702-616-0500
Fax Number	:	702-616-0505

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KENNETH J. SHAH
Credential	:	M.D.
Telephone Number	:	702-616-0500

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	05/10/2022

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