Provider Demographics
NPI:1396959136
Name:COLON, RECTAL AND LASER SURGERY ASSOCIATES, INC.
Entity type:Organization
Organization Name:COLON, RECTAL AND LASER SURGERY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJU
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-893-2622
Mailing Address - Street 1:5705 MONCLOVA RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1875
Mailing Address - Country:US
Mailing Address - Phone:419-893-2622
Mailing Address - Fax:419-893-2755
Practice Address - Street 1:5705 MONCLOVA RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1875
Practice Address - Country:US
Practice Address - Phone:419-893-2622
Practice Address - Fax:419-893-2755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9336781Medicare ID - Type Unspecified