Provider Demographics
NPI:1205083466
Name:ABOLGHASSEM SHEIBAN, M.D., P.A.
Entity type:Organization
Organization Name:ABOLGHASSEM SHEIBAN, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABOLGHASSEM
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHEIBAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-445-0469
Mailing Address - Street 1:190 DAYTON ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4422
Mailing Address - Country:US
Mailing Address - Phone:201-445-0469
Mailing Address - Fax:201-447-4755
Practice Address - Street 1:190 DAYTON ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4422
Practice Address - Country:US
Practice Address - Phone:201-445-0469
Practice Address - Fax:201-447-4755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02281800173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C53619Medicare UPIN