Provider Demographics
NPI:1720013535
Name:LI, SHAN (MD)
Entity Type:Individual
Prefix:
First Name:SHAN
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1610
Mailing Address - Country:US
Mailing Address - Phone:413-827-7426
Mailing Address - Fax:413-827-7407
Practice Address - Street 1:759 CHESTNUT ST
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1619
Practice Address - Country:US
Practice Address - Phone:413-827-7426
Practice Address - Fax:413-827-7407
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1610582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3200523Medicaid
MAA30201Medicare ID - Type Unspecified
MA3200523Medicaid