Basic Information
| Provider Information | |||||||||
| NPI: | 1457428559 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAJIV S SHAH PHYSICIAN P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2337 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132202337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154222933 | ||||||||
| FaxNumber: | 3154223909 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 CLAY ST | ||||||||
| Address2: | |||||||||
| City: | MALONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129531905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184830705 | ||||||||
| FaxNumber: | 5184831375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 11/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | SHAH | ||||||||
| AuthorizedOfficialFirstName: | RAJIV | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5184830705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 168997 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | 168997 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | DF8170 | 01 | NY | RAILROAD MEDICARE | OTHER |