Healthcare Provider Details

I. General information

NPI: 1710100367
Provider Name (Legal Business Name): SHEFALI BHUSNURMATH GOYAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHEFALI SHIVAYOGI BHUSNURMATH M.D.

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE CHANDLER BLDG 4TH FLOOR
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

877 JEFFERSON AVE ATTN: PROVIDER ENROLLMENT
MEMPHIS TN
38103-2807
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-7558
  • Fax:
Mailing address:
  • Phone: 901-545-7558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberMD60164230
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberMD 60164230
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number01066212A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number003386-1
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number50663
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: