Basic Information
Provider Information | |||||||||
NPI: | 1144259649 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAMI | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | GEORGE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1130 MCBRIDE AVE FL 3 | ||||||||
Address2: |   | ||||||||
City: | WOODLAND PARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 074243806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9738121400 | ||||||||
FaxNumber: | 9738121404 | ||||||||
Practice Location | |||||||||
Address1: | 205 BROWERTOWN RD STE 204 | ||||||||
Address2: |   | ||||||||
City: | WOODLAND PARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 074242610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9738125230 | ||||||||
FaxNumber: | 9738125235 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2006 | ||||||||
LastUpdateDate: | 04/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 25MA03848700 | NJ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 1703803 | 05 | NJ |   | MEDICAID |