Basic Information
| Provider Information | |||||||||
| NPI: | 1124006507 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | PURNA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OLD COUNTRY ROAD | ||||||||
| Address2: | #278 LONG ISLAND HEART ASSOCIATES | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168770977 | ||||||||
| FaxNumber: | 5162946861 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 OLD COUNTRY ROAD | ||||||||
| Address2: | #278 LONG ISLAND HEART ASSOCIATES | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168770977 | ||||||||
| FaxNumber: | 5162946861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2211851 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02184834 | 05 | NY | MEDICAID |