Provider Demographics
NPI:1386614113
Name:SHAH, SAIRAV B (MD)
Entity type:Individual
Prefix:DR
First Name:SAIRAV
Middle Name:B
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3011
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82717-3011
Mailing Address - Country:US
Mailing Address - Phone:307-688-3700
Mailing Address - Fax:
Practice Address - Street 1:501 S BURMA AVENUE
Practice Address - Street 2:STE 3500
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3426
Practice Address - Country:US
Practice Address - Phone:307-688-3700
Practice Address - Fax:307-688-7920
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9196A207R00000X, 207RI0011X
AZ35154207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ099093Medicaid
AZ099093Medicaid
AZZ109591Medicare PIN