Provider Demographics
NPI:1013962802
Name:SHIRLEY MATHEW MD PLLC
Entity Type:Organization
Organization Name:SHIRLEY MATHEW MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-829-8777
Mailing Address - Street 1:287 NORTHERN BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4717
Mailing Address - Country:US
Mailing Address - Phone:516-829-8777
Mailing Address - Fax:516-829-7926
Practice Address - Street 1:287 NORTHERN BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4717
Practice Address - Country:US
Practice Address - Phone:516-829-8777
Practice Address - Fax:516-829-7926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY57561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEZ221Medicare ID - Type Unspecified