Provider Demographics
NPI:1194925776
Name:CHETAN D. SHAH, M.D.,PLLC
Entity type:Organization
Organization Name:CHETAN D. SHAH, M.D.,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHETAN
Authorized Official - Middle Name:DINESHBHAI
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-775-4056
Mailing Address - Street 1:163 WALNUT GROVE CHURCH RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-5905
Mailing Address - Country:US
Mailing Address - Phone:423-775-4056
Mailing Address - Fax:423-775-1054
Practice Address - Street 1:163 WALNUT GROVE CHURCH RD
Practice Address - Street 2:SUITE 102
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-5905
Practice Address - Country:US
Practice Address - Phone:423-775-4056
Practice Address - Fax:423-775-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD31883207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3727827 GROUP IDMedicare PIN