Provider Demographics
NPI:1457428559
Name:RAJIV S SHAH PHYSICIAN P C
Entity Type:Organization
Organization Name:RAJIV S SHAH PHYSICIAN P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RAJIV
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-483-0705
Mailing Address - Street 1:PO BOX 2337
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-2337
Mailing Address - Country:US
Mailing Address - Phone:315-422-2933
Mailing Address - Fax:315-422-3909
Practice Address - Street 1:5 CLAY ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1905
Practice Address - Country:US
Practice Address - Phone:518-483-0705
Practice Address - Fax:518-483-1375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168997207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDF8170OtherRAILROAD MEDICARE
NY51120BMedicare PIN
NYDF8170OtherRAILROAD MEDICARE