Basic Information
| Provider Information | |||||||||
| NPI: | 1891755666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAHANE | ||||||||
| FirstName: | MANOJ | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 48078 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071014878 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 33 OVERLOOK RD | ||||||||
| Address2: | STE. 311 | ||||||||
| City: | SUMMIT | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079013570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003944445 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 02/07/2008 | ||||||||
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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 | 207L00000X | 25MA07365100 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 8844607 | 05 | NJ | MEDICAID |