Basic Information
| Provider Information | |||||||||
| NPI: | 1477582930 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | SHIRISHKUMAR | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 COPPER CREEK DR | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423031797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709930755 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 PLEASANT VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423039811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704174700 | ||||||||
| FaxNumber: | 2704174709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 12/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 31587 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64315872 | 05 | KY | MEDICAID | 200063470 | 05 | IN | MEDICAID |