Healthcare Provider Details

I. General information

NPI: 1700149895
Provider Name (Legal Business Name): SHAISTA ALAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 10/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 WALNUT ST FL 2
PHILADELPHIA PA
19107-5211
US

IV. Provider business mailing address

909 WALNUT ST FL 2
PHILADELPHIA PA
19107-5211
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-7952
  • Fax: 215-503-7007
Mailing address:
  • Phone: 215-955-7952
  • Fax: 215-503-7007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberMT202598
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD457769
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: