MEDICARE: EVERGREEN EAR, NOSE & THROAT SURGERY P.C.

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	207Y00000X	Otolaryngology Physician

General Provider Information

NPI Number	:	1982622817
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN EAR, NOSE & THROAT SURGERY P.C.

Provider Business Mailing Address
First Line	:	34 FARM LN
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11020-1314
Country	:	US
Telephone Number	:	516-581-5099
Fax Number	:	516-706-0622

Provider Business Practice Location Address
First Line	:	728 E PARK AVE
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-2605
Country	:	US
Telephone Number	:	516-431-0700
Fax Number	:	516-706-0622

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SHEFALI SHAH
Credential	:	M.D.
Telephone Number	:	516-431-0700

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	04/13/2016

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