Provider Demographics
NPI:1245211663
Name:SHAH, SOVRIN M (MD)
Entity Type:Individual
Prefix:
First Name:SOVRIN
Middle Name:M
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95000-2227
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2227
Mailing Address - Country:US
Mailing Address - Phone:212-844-8926
Mailing Address - Fax:
Practice Address - Street 1:10 UNION SQUARE EAST
Practice Address - Street 2:SUITE 3A BIMC DEPT OF UROLOGY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-844-8926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2110611208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02573435Medicaid
NY02573435Medicaid
NY36R521Medicare ID - Type Unspecified