| Entity Name: | AMIT I. SHAH, M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 11 Feb 1998 (27 years ago) |
| Document Number: | P98000013627 |
| FEI/EIN Number | 650826332 |
| Address: | 4420 SUN N LAKE BLVD, SEBRING, FL, 33872 |
| Mail Address: | 4420 SUN N LAKE BLVD, SEBRING, FL, 33872 |
| ZIP code: | 33872 |
| County: | Highlands |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1881733772 | 2007-02-06 | 2008-11-05 | 4420 SUN N LAKE BLVD, SEBRING, FL, 338722164, US | 4420 SUN N LAKE BLVD, SEBRING, FL, 338722164, US | |||||||||||||||||||||||||
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| Phone | +1 863-385-1244 |
| Fax | 8633856086 |
Authorized person
| Name | MS. THERESA MARTINEZ |
| Role | FINANCIAL SERVICES |
| Phone | 8633851244 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | ME48069 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 045758200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SHAH AMIT I | Agent | 4420 SUN N LAKE BOULEVARD, SEBRING, FL, 33872 |
| Name | Role | Address |
|---|---|---|
| SHAH AMIT I | President | 4420 SUN N LAKE BLVD, SEBRING, FL, 33872 |
| AHMED SYED | President | 4420 SUN N LAKE BLVD., SEBRING, FL, 33872 |
| Name | Role | Address |
|---|---|---|
| SHAH AMIT I | Director | 4420 SUN N LAKE BLVD, SEBRING, FL, 33872 |
| AHMED SYED | Director | 4420 SUN N LAKE BLVD., SEBRING, FL, 33872 |
| Name | Role | Address |
|---|---|---|
| SHAH PARUL | Secretary | 4420 SUN N LAKE BLVD, SEBRING, FL, 33872 |
| Name | Role | Address |
|---|---|---|
| SHAH PARUL | Treasurer | 4420 SUN N LAKE BLVD, SEBRING, FL, 33872 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2014-12-22 | No data | No data |
| CANCEL ADM DISS/REV | 2005-10-03 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2005-09-16 | No data | No data |
| AMENDMENT AND NAME CHANGE | 1998-02-27 | AMIT I. SHAH, M.D., P.A. | No data |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
