Provider Demographics
NPI:1477591097
Name:EIN ALSHAEBA, SAMER (MD)
Entity Type:Individual
Prefix:MR
First Name:SAMER
Middle Name:
Last Name:EIN ALSHAEBA
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 1:95 SCOVILL ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1113
Mailing Address - Country:US
Mailing Address - Phone:203-465-5292
Mailing Address - Fax:203-465-5296
Practice Address - Street 1:95 SCOVILL ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1113
Practice Address - Country:US
Practice Address - Phone:203-465-5292
Practice Address - Fax:203-465-5296
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001940207R00000X
AZ36185207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02635812Medicaid
AZ150734Medicaid
I02165Medicare UPIN
AZZ138882Medicare PIN
AZZ111688Medicare PIN
NY02635812Medicaid
AZZ138882Medicare PIN