Provider Demographics
NPI:1386907707
Name:DR. YOGENDRA A. SHAH, MD. SC
Entity type:Organization
Organization Name:DR. YOGENDRA A. SHAH, MD. SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GYN
Authorized Official - Prefix:DR
Authorized Official - First Name:YOGENDRA
Authorized Official - Middle Name:AMBALAL
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-451-7717
Mailing Address - Street 1:3165 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-5012
Mailing Address - Country:US
Mailing Address - Phone:618-451-7717
Mailing Address - Fax:618-451-7780
Practice Address - Street 1:3165 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-5012
Practice Address - Country:US
Practice Address - Phone:618-451-7717
Practice Address - Fax:618-451-7780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048989174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048989Medicaid
IL036048989Medicaid
IL649060Medicare PIN