Provider Demographics
NPI:1902833288
Name:SHAHLA MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:SHAHLA MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ZIAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-948-3444
Mailing Address - Street 1:8800 TERRENE CT STE 102
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-9900
Mailing Address - Country:US
Mailing Address - Phone:239-948-3444
Mailing Address - Fax:239-948-9028
Practice Address - Street 1:8800 TERRENE CT STE 102
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-9900
Practice Address - Country:US
Practice Address - Phone:239-948-3444
Practice Address - Fax:239-948-9028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066854207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26304OtherBC
FL110188758OtherRAILROAD MEDICARE
FLN/AMedicaid
FLF92847Medicare UPIN