Provider Demographics
NPI:1396871422
Name:SHAH, BASHARAT A (MD)
Entity type:Individual
Prefix:DR
First Name:BASHARAT
Middle Name:A
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:119 BOONE RIDGE DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-1325
Mailing Address - Country:US
Mailing Address - Phone:423-282-1480
Mailing Address - Fax:423-928-1353
Practice Address - Street 1:1 MEDICAL PARK BLVD.
Practice Address - Street 2:BRISTOL REGIONAL MEDICAL CENTER
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-282-1480
Practice Address - Fax:423-928-1353
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2013-10-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036.116972207R00000X
WI50541-020207R00000X
VA0101250967207R00000X
TN48226208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34918800Medicaid
WI60714OtherDEAN HEALTH INSURANCE
WI34918800Medicaid
WI011554375Medicare PIN