Healthcare Provider Details

I. General information

NPI: 1457428559
Provider Name (Legal Business Name): RAJIV S SHAH PHYSICIAN P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 11/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CLAY ST
MALONE NY
12953-1905
US

IV. Provider business mailing address

PO BOX 2337
SYRACUSE NY
13220-2337
US

V. Phone/Fax

Practice location:
  • Phone: 518-483-0705
  • Fax: 518-483-1375
Mailing address:
  • Phone: 315-422-2933
  • Fax: 315-422-3909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number168997
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number168997
License Number StateNY

VIII. Authorized Official

Name: RAJIV SHAH
Title or Position: SOLE MEMBER
Credential: MD
Phone: 518-483-0705