Basic Information
Provider Information | |||||||||
NPI: | 1871157057 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JAWAD A SHAH MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4800 S SAGINAW ST | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485072677 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8107328336 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4800 S SAGINAW ST | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485072677 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8107328336 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2019 | ||||||||
LastUpdateDate: | 04/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | IJAZ | ||||||||
AuthorizedOfficialFirstName: | MOHAMMAD | ||||||||
AuthorizedOfficialMiddleName: | NADIR | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8102759371 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | JAWAD A SHAH MD PC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Case Management | 251B00000X |   |   | Y |   | Agencies | Case Management |   |
No ID Information.