Basic Information
| Provider Information | |||||||||
| NPI: | 1578689691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANT | ||||||||
| FirstName: | SHRUTI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11407 DRAWER 646 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352460646 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 7TH AVE S | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352331711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059399587 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD.29495 | AL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208000000X | 12798 | NV | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD.29495 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 110350 | 05 | AL | MEDICAID | 110305 | 05 | AL | MEDICAID | 1578689691 | 01 | AL | TRICARE SOUTH | OTHER | 515-98320 | 01 | AL | BCBS | OTHER | 515-98454 | 01 | AL | BCBS | OTHER | 100500484 | 05 | NV | MEDICAID |