Provider Demographics
NPI:1124167333
Name:DR SHAH CLINIC
Entity type:Organization
Organization Name:DR SHAH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DINESH
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-247-2100
Mailing Address - Street 1:225 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-2240
Mailing Address - Country:US
Mailing Address - Phone:270-247-2100
Mailing Address - Fax:270-247-2113
Practice Address - Street 1:225 W WATER ST
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-2240
Practice Address - Country:US
Practice Address - Phone:270-247-2100
Practice Address - Fax:270-247-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26092207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4219055OtherAETNA
KY64260920Medicaid
KY000000341370OtherBCBS
KY1958601Medicare ID - Type Unspecified
KYB85245Medicare UPIN