Basic Information
| Provider Information | |||||||||
| NPI: | 1609184480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAILESH | ||||||||
| FirstName: | FNU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 LEWIS RD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139051048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4417 VESTAL PKWY E | ||||||||
| Address2: | |||||||||
| City: | VESTAL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138503556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2010 | ||||||||
| LastUpdateDate: | 04/25/2017 | ||||||||
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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 | 207RC0000X | 283098 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 04503760 | 05 | NY | MEDICAID |