Provider Demographics
NPI:1982622817
Name:EVERGREEN EAR, NOSE & THROAT SURGERY P.C.
Entity Type:Organization
Organization Name:EVERGREEN EAR, NOSE & THROAT SURGERY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEFALI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-431-0700
Mailing Address - Street 1:34 FARM LN
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11020-1314
Mailing Address - Country:US
Mailing Address - Phone:516-581-5099
Mailing Address - Fax:516-706-0622
Practice Address - Street 1:728 E PARK AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-2605
Practice Address - Country:US
Practice Address - Phone:516-431-0700
Practice Address - Fax:516-706-0622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEP511Medicare UPIN