MEDICARE: SHRISTI SHAH M.D

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	2084P0804X	Child & Adolescent Psychiatry Physician	4301100311	MI

General Provider Information

NPI Number	:	1639303712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHRISTI SHAH M.D

Provider Business Mailing Address
First Line	:	300 68TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49548-6927
Country	:	US
Telephone Number	:	616-455-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4211 PARKWAY PL SW
Second Line	:
City	:	GRANDVILLE
State	:	MI
Zip	:	49418-2695
Country	:	US
Telephone Number	:	616-222-3700
Fax Number	:

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

Provider Enumeration Date	:	05/05/2009
Last Update Date	:	02/11/2022

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