Provider Demographics
NPI:1255458543
Name:GREGORY B. SHANKMAN, M.D., P.C.
Entity type:Organization
Organization Name:GREGORY B. SHANKMAN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-797-0111
Mailing Address - Street 1:PO BOX 8190
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13505-8190
Mailing Address - Country:US
Mailing Address - Phone:315-797-0111
Mailing Address - Fax:315-735-3459
Practice Address - Street 1:1418 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5101
Practice Address - Country:US
Practice Address - Phone:135-797-0111
Practice Address - Fax:315-735-3459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134913174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY134913OtherNY STATE LICENSE
NY00560072Medicaid
NY134913OtherNY STATE LICENSE
NYB81765Medicare UPIN