Basic Information
| Provider Information | |||||||||
| NPI: | 1689641730 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SHAH | ||||||||
| FirstName: | AJIT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24651 CENTER RIDGE RD | ||||||||
| Address2: | STE 350 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441455635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 7215 OLD OAK BLVD | ||||||||
| Address2: | STE A 414 | ||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408162782 | ||||||||
| FaxNumber: | 4408168695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 35045151S | OH | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 040017966 | 01 | RR MEDICARE INDIVIDUAL | OTHER | CA4511 | 01 | RR MEDICARE GROUP | OTHER | 0799864 | 05 | OH | MEDICAID |