Basic Information
| Provider Information | |||||||||
| NPI: | 1881733772 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMIT I SHAH M D P A | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4420 SUN N LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | SEBRING | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338722164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633851244 | ||||||||
| FaxNumber: | 8633856086 | ||||||||
| Practice Location | |||||||||
| Address1: | 4420 SUN N LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | SEBRING | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338722164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633851244 | ||||||||
| FaxNumber: | 8633856086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 11/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | MARTINEZ | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8633851244 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME48069 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 045758200 | 05 | FL | MEDICAID |