Basic Information
| Provider Information | |||||||||
| NPI: | 1346779501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERCITY GASTROENTEROLOGY P.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 957 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110402821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167848331 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19303 UNION TPKE | ||||||||
| Address2: | |||||||||
| City: | FRESH MEADOWS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113661874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167214648 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2017 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | SHAHZAD | ||||||||
| AuthorizedOfficialFirstName: | GHULAMULLAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5167848331 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 252160 | NY | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 03190443 | 05 | NY | MEDICAID |