MEDICARE: DR. ROGER BRIAN SHAMBO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	165521-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	374498	OTHER	NY	MVP

General Provider Information

NPI Number	:	1649251489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER BRIAN SHAMBO MD

Provider Business Mailing Address
First Line	:	9559 MAIN STREET
Second Line	:	PO BOX 180
City	:	BEAVER FALLS
State	:	NY
Zip	:	13305-0180
Country	:	US
Telephone Number	:	315-346-6824
Fax Number	:	315-346-6868

Provider Business Practice Location Address
First Line	:	9559 MAIN STREET
Second Line	:
City	:	BEAVER FALLS
State	:	NY
Zip	:	13305
Country	:	US
Telephone Number	:	315-346-6824
Fax Number	:	315-346-6868

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	01/17/2022

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