Healthcare Provider Details

I. General information

NPI: 1629582572
Provider Name (Legal Business Name): SHAMIM GHADAMI CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

IV. Provider business mailing address

PO BOX 1123
JACKSON MI
49204-1123
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-2663
  • Fax:
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-7365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2312003
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN55766
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: