MEDICARE: BIJAL SHAH MODI PA 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	2088P0231X	Pediatric Urology Physician	036 071644	IL

General Provider Information

NPI Number	:	1518157445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BIJAL SHAH MODI PA C

Provider Business Mailing Address
First Line	:	381 PARK AVE S
Second Line	:	SUITE 1020
City	:	NEW YORK
State	:	NY
Zip	:	10016-8806
Country	:	US
Telephone Number	:	212-260-6078
Fax Number	:	212-260-6185

Provider Business Practice Location Address
First Line	:	381 PARK AVE S
Second Line	:	SUITE 1020
City	:	NEW YORK
State	:	NY
Zip	:	10016-8806
Country	:	US
Telephone Number	:	212-260-6078
Fax Number	:	212-260-6185

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

Provider Enumeration Date	:	07/26/2007
Last Update Date	:	04/07/2009

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