Basic Information
| Provider Information | |||||||||
| NPI: | 1649251489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAMBO | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | BRIAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9559 MAIN STREET | ||||||||
| Address2: | PO BOX 180 | ||||||||
| City: | BEAVER FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133050180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153466824 | ||||||||
| FaxNumber: | 3153466868 | ||||||||
| Practice Location | |||||||||
| Address1: | 9559 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | BEAVER FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153466824 | ||||||||
| FaxNumber: | 3153466868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 165521-1 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01021076 | 05 | NY | MEDICAID | 374498 | 01 | NY | MVP | OTHER |