Provider Demographics
NPI:1730314261
Name:MOOSSAVI, SHAHAB (MD)
Entity Type:Individual
Prefix:
First Name:SHAHAB
Middle Name:
Last Name:MOOSSAVI
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 1:246 PLEASANT STREET MEMORIAL BUILDING, WEST, GROUND FLO
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2548
Mailing Address - Country:US
Mailing Address - Phone:603-224-6070
Mailing Address - Fax:603-224-6094
Practice Address - Street 1:246 PLEASANT STREET MEMORIAL BUILDING, WEST, GROUND FLO
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2548
Practice Address - Country:US
Practice Address - Phone:603-224-6070
Practice Address - Fax:603-224-6094
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420012514207R00000X, 208M00000X
NH17433207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1021072Medicaid
VT002965001Medicare PIN
VT1021072Medicaid