Basic Information
| Provider Information | |||||||||
| NPI: | 1053329797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | SPENCER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5801 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100875801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9145937880 | ||||||||
| FaxNumber: | 9145937881 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 GREENRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106051237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143288555 | ||||||||
| FaxNumber: | 9145937881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 04/03/2009 | ||||||||
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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 | 207RG0100X | 109224 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | P00600058 | 01 | NY | RR MEDICARE | OTHER |