Provider Demographics
NPI:1568494755
Name:SHALLISH, NEIL FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:FREDERICK
Last Name:SHALLISH
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 1:120 LARCHMONT DR
Mailing Address - Street 2:
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-9718
Mailing Address - Country:US
Mailing Address - Phone:607-387-5890
Mailing Address - Fax:
Practice Address - Street 1:209 W STATE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5429
Practice Address - Country:US
Practice Address - Phone:607-277-4341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00705660Medicaid
NY37084EMedicare ID - Type Unspecified
NY00705660Medicaid