Basic Information
| Provider Information | |||||||||
| NPI: | 1053604694 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SHADIANLOO | ||||||||
| FirstName: | SHERVIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7559 263RD ST | ||||||||
| Address2: | THE ZUCKER HILLSIDE HOSPITAL ACP BUILDING | ||||||||
| City: | GLEN OAKS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110041150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184704834 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7559 263RD ST | ||||||||
| Address2: | THE ZUCKER HILLSIDE HOSPITAL ACP BUILDING | ||||||||
| City: | GLEN OAKS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110041150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184704834 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2011 | ||||||||
| LastUpdateDate: | 07/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 141090 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | 277220 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.