Healthcare Provider Details

I. General information

NPI: 1669434049
Provider Name (Legal Business Name): ERUM SHAHAB M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 MAIN ST
ELLINGTON CT
06029-3360
US

IV. Provider business mailing address

16 MAIN ST
ELLINGTON CT
06029-3360
US

V. Phone/Fax

Practice location:
  • Phone: 860-871-5402
  • Fax: 860-871-5413
Mailing address:
  • Phone: 860-871-5402
  • Fax: 860-871-5413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number0431121
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number043112
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0431121
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: