Basic Information
| Provider Information | |||||||||
| NPI: | 1952544561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHATAVI | ||||||||
| FirstName: | SEERIN | ||||||||
| MiddleName: | VIVIANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3035 HAMILTON MASON RD STE 204 | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450115545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138531300 | ||||||||
| FaxNumber: | 5134514118 | ||||||||
| Practice Location | |||||||||
| Address1: | 3035 HAMILTON MASON RD STE 204 | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450115545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138531300 | ||||||||
| FaxNumber: | 5134514118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2009 | ||||||||
| LastUpdateDate: | 11/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125053868 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 130298 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 35130298 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0207910 | 05 | OH | MEDICAID |