Provider Demographics
NPI:1467709451
Name:ADVANCED INTERNAL MEDICINE, P.C.
Entity Type:Organization
Organization Name:ADVANCED INTERNAL MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:SHAMEKH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-455-7017
Mailing Address - Street 1:130 GRISTMILL LN
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-1839
Mailing Address - Country:US
Mailing Address - Phone:516-455-7017
Mailing Address - Fax:
Practice Address - Street 1:935 NORTHERN BLVD STE 105
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5309
Practice Address - Country:US
Practice Address - Phone:516-487-0070
Practice Address - Fax:516-487-0072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-08
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236142207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02708294Medicaid
NY02708294Medicaid