Provider Demographics
NPI:1972743326
Name:SHADEFAI GOLDSMITH
Entity Type:Organization
Organization Name:SHADEFAI GOLDSMITH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PRACTICAL NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:SHADEFAI
Authorized Official - Middle Name:ZSALINN
Authorized Official - Last Name:GOLDSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-413-3762
Mailing Address - Street 1:929 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14615-3824
Mailing Address - Country:US
Mailing Address - Phone:585-734-4484
Mailing Address - Fax:
Practice Address - Street 1:929 RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14615-3824
Practice Address - Country:US
Practice Address - Phone:585-734-4484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295552305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service