MEDICARE: MR. HARDIK M SHAH D.O.

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	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	5101010763	MI
2	207Q00000X	Family Medicine Physician	HS010763	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	383397259	OTHER	MI	TAX IDENTIFICATION
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508852765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HARDIK M SHAH D.O.

Provider Business Mailing Address
First Line	:	4300 MARSEILLES ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48224-1479
Country	:	US
Telephone Number	:	313-290-2250
Fax Number	:	313-290-2257

Provider Business Practice Location Address
First Line	:	4300 MARSEILLES ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48224-1479
Country	:	US
Telephone Number	:	313-290-2250
Fax Number	:	313-290-2257

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

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	12/10/2018

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Directions to “ MR. HARDIK M SHAH D.O.” Practice Location

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