Provider Demographics
NPI:1619462199
Name:SHOL, MAC
Entity Type:Individual
Prefix:
First Name:MAC
Middle Name:
Last Name:SHOL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 POND ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13208-2117
Mailing Address - Country:US
Mailing Address - Phone:315-640-5457
Mailing Address - Fax:
Practice Address - Street 1:515 POND ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13208-2117
Practice Address - Country:US
Practice Address - Phone:315-640-5457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY824371046OtherNON EMERGENCY MEDICAID TRANSPORT