Provider Demographics
NPI:1639414121
Name:SHAH, SYED SALEEM (BS,MS)
Entity Type:Individual
Prefix:
First Name:SYED
Middle Name:SALEEM
Last Name:SHAH
Suffix:
Gender:M
Credentials:BS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 RAMS HORN ROW
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-5978
Mailing Address - Country:US
Mailing Address - Phone:954-288-5257
Mailing Address - Fax:410-563-1147
Practice Address - Street 1:2245 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-3113
Practice Address - Country:US
Practice Address - Phone:410-675-6046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD666064001Medicare UPIN