Basic Information
| Provider Information | |||||||||
| NPI: | 1255521332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | REHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 18TH ST E | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293914100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2225 US HIGHWAY 41 N | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317942749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293914100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2007 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 071567 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | MD61072096 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 071567 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RN0300X | S2503 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 2173910 | 05 | WA | MEDICAID |