Provider Demographics
NPI:1942317060
Name:IDRIS, SYED ALI SHAN (MD; MBBS)
Entity Type:Individual
Prefix:
First Name:SYED ALI SHAN
Middle Name:
Last Name:IDRIS
Suffix:
Gender:M
Credentials:MD; MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5965 E BROAD ST STE 260
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1562
Mailing Address - Country:US
Mailing Address - Phone:641-866-3703
Mailing Address - Fax:614-866-6109
Practice Address - Street 1:5965 EASY BROAD STREET, SUITE 260
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213
Practice Address - Country:US
Practice Address - Phone:641-866-3703
Practice Address - Fax:614-866-6109
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35087057207R00000X, 208000000X
OH35.0870572084N0400X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2697489Medicaid
OHP00352662OtherRAILROAD
OH000000494609OtherANTHEM
OHP00352662OtherRAILROAD
OHI64665Medicare UPIN
OH2697489Medicaid