Basic Information
| Provider Information | |||||||||
| NPI: | 1457564601 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHINGAREV | ||||||||
| FirstName: | ROMAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 55310 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352555310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057319701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 61919TH ST S | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352490001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059345038 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 10/28/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 27857 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 130859 | 05 | AL | MEDICAID | 051119646 | 01 | AL | BCBS | OTHER | Z21075 | 01 | AL | VIVA | OTHER | 130858 | 05 | AL | MEDICAID | 051119633 | 01 | AL | BCBS | OTHER | 06250501 | 05 | MS | MEDICAID | 051119647 | 01 | AL | BCBS | OTHER | 130856 | 05 | AL | MEDICAID |