MEDICARE: SURYAKANT SHAH 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	207Q00000X	Family Medicine Physician	228300-1	NY

General Provider Information

NPI Number	:	1629079249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SURYAKANT SHAH MD

Provider Business Mailing Address
First Line	:	1890 PALMER AVE STE 304
Second Line	:
City	:	LARCHMONT
State	:	NY
Zip	:	10538-3031
Country	:	US
Telephone Number	:	914-834-9606
Fax Number	:	914-834-0648

Provider Business Practice Location Address
First Line	:	1890 PALMER AVE STE 304
Second Line	:
City	:	LARCHMONT
State	:	NY
Zip	:	10538-3031
Country	:	US
Telephone Number	:	914-834-9606
Fax Number	:	914-834-0648

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

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	05/18/2012

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