Provider Demographics
NPI:1891034500
Name:GASTROENTEROLOGY & LIVER DISEASE, PC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY & LIVER DISEASE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALOMOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-520-0857
Mailing Address - Street 1:10721 QUEENS BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4413
Mailing Address - Country:US
Mailing Address - Phone:718-520-0857
Mailing Address - Fax:718-520-9099
Practice Address - Street 1:10721 QUEENS BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4413
Practice Address - Country:US
Practice Address - Phone:718-520-0857
Practice Address - Fax:718-520-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-01
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244590174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02914441Medicaid