Provider Demographics
NPI:1891890612
Name:SHAN, SHAHEENA (MD)
Entity Type:Individual
Prefix:
First Name:SHAHEENA
Middle Name:
Last Name:SHAN
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:P.O. BOX 415933
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5933
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR STREET
Practice Address - Street 2:HARTFORD HOSPITAL INFECTIOUS DISEASE
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-5037
Practice Address - Country:US
Practice Address - Phone:860-545-2878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039691207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001396910Medicaid
CT110009127Medicare ID - Type Unspecified
CT001396910Medicaid