Basic Information
| Provider Information | |||||||||
| NPI: | 1508867961 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHENDE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 IRVING AVE | ||||||||
| Address2: | STE. 503 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644470 | ||||||||
| FaxNumber: | 3154645520 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 IRVING AVE | ||||||||
| Address2: | STE. 503 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644470 | ||||||||
| FaxNumber: | 3154645520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 10/17/2013 | ||||||||
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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 | 207T00000X | 107334 | NY | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00402795 | 05 | NY | MEDICAID |