Basic Information
| Provider Information | |||||||||
| NPI: | 1609934330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | VIPUL | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3130 GRANDVIEW RD | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173319134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176322088 | ||||||||
| FaxNumber: | 7176379482 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 BRUNSWICK DR STE 1300 | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173318350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176322088 | ||||||||
| FaxNumber: | 7176467428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 12/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD432452 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1020489640001 | 05 | PA | MEDICAID | 2509048 | 05 | OH | MEDICAID |