Healthcare Provider Details

I. General information

NPI: 1609027051
Provider Name (Legal Business Name): MANASI M SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE CANCER CENTER
FARMINGTON CT
06030-2875
US

IV. Provider business mailing address

263 FARMINGTON AVE PROVIDER ENROLLMENT OFFICE
FARMINGTON CT
06030-2212
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2100
  • Fax: 860-679-4815
Mailing address:
  • Phone: 860-679-7503
  • Fax: 860-679-1610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number047829
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number047829
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: