Provider Demographics
NPI:1043206048
Name:NI, GLEN SHAW (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:SHAW
Last Name:NI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:907 SUMNER ST
Mailing Address - Street 2:SUITE M201 GUARDIAN ANESTHESIA INC
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072
Mailing Address - Country:US
Mailing Address - Phone:781-344-2325
Mailing Address - Fax:781-341-8544
Practice Address - Street 1:907 SUMNER ST
Practice Address - Street 2:GUARDIAN ANESTHESIA INC
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072
Practice Address - Country:US
Practice Address - Phone:781-344-2325
Practice Address - Fax:781-341-8544
Is Sole Proprietor?:No
Enumeration Date:2005-09-25
Last Update Date:2008-04-07
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Provider Licenses
StateLicense IDTaxonomies
NY230098207L00000X
MA228264207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I68151Medicare UPIN
A40944Medicare PIN