Provider Demographics
NPI:1336221696
Name:SHYAM C. SHIVDASANI, MD INTERNAL MEDICINE PLLC
Entity Type:Organization
Organization Name:SHYAM C. SHIVDASANI, MD INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MS
Authorized Official - First Name:SHALEEN
Authorized Official - Middle Name:MAKHIJANI
Authorized Official - Last Name:SHIVDASANI
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:516-242-1430
Mailing Address - Street 1:21 RENI RD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-1222
Mailing Address - Country:US
Mailing Address - Phone:516-869-3210
Mailing Address - Fax:516-627-0464
Practice Address - Street 1:140 LOCKWOOD AVE
Practice Address - Street 2:SUITE #216
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-4915
Practice Address - Country:US
Practice Address - Phone:914-235-6900
Practice Address - Fax:914-235-7900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196192207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3359089OtherAETNA HMO #
NY3C2846OtherHEALTHNET (PHS) #
NY1896297OtherCIGNA #
NYWP738OtherOXFORD #
NY01851505Medicaid
NY0203874OtherGHI NON-PAR #
NY196192OtherHIP #
NY2592106OtherGHI #
NYDE7187OtherMEDICARE RAILROAD
NYSS6192OtherATLANTIS HEALTHPLAN #
NY002918OtherCONNECICARE #
NY5387184OtherAETNA PPO #
NY163AJ3OtherEMPIRE BC/BS #
NY01851505Medicaid
NYWP738OtherOXFORD #
NYWGC681Medicare PIN