Basic Information
| Provider Information | |||||||||
| NPI: | 1487844205 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | NEIL | ||||||||
| MiddleName: | ASHVIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2603 39TH AVE NE STE D202 | ||||||||
| Address2: | |||||||||
| City: | SAINT ANTHONY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554214372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122132370 | ||||||||
| FaxNumber: | 6122132370 | ||||||||
| Practice Location | |||||||||
| Address1: | 2603 39TH AVE NE STE D202 | ||||||||
| Address2: | |||||||||
| City: | SAINT ANTHONY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554214372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122132370 | ||||||||
| FaxNumber: | 6122132370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2007 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | 50969 | MN | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | 50969 | MN | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | MN | MEDICAID | P00813436 | 01 | MN | RAILROAD MEDICARE | OTHER |