Provider Demographics
NPI:1821233305
Name:SYED SHAFEEQ UR RAHMAN PA
Entity type:Organization
Organization Name:SYED SHAFEEQ UR RAHMAN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:SYED SHAFEEQ
Authorized Official - Middle Name:UR
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-468-6969
Mailing Address - Street 1:805 VIRGINIA AVE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5881
Mailing Address - Country:US
Mailing Address - Phone:772-468-6969
Mailing Address - Fax:772-465-5160
Practice Address - Street 1:805 VIRGINIA AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5881
Practice Address - Country:US
Practice Address - Phone:772-468-6969
Practice Address - Fax:772-465-5160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-11
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86628261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260888000Medicaid
FLU0872Medicare UPIN