Basic Information
| Provider Information | |||||||||
| NPI: | 1194878793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHOUB | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 407 AIRPORT EXE PARK | ||||||||
| Address2: | |||||||||
| City: | NANUET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10954 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 339 HICKS ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112015509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187801961 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 02/11/2010 | ||||||||
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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 | 207P00000X | 222435 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02407454 | 05 | NY | MEDICAID | 3007132 | 05 | OH | MEDICAID |