Healthcare Provider Details

I. General information

NPI: 1750386975
Provider Name (Legal Business Name): SHELLA FAROOKI M.D., M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27005 KNICKERBOCKER RD STE 100
BAY VILLAGE OH
44140
US

IV. Provider business mailing address

27005 KNICKERBOCKER RD STE 100
BAY VILLAGE OH
44140-2388
US

V. Phone/Fax

Practice location:
  • Phone: 805-620-2699
  • Fax: 800-616-0084
Mailing address:
  • Phone: 888-365-5514
  • Fax: 800-616-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number35078150
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD36487
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: