=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649546946
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRIAM SHUSTIK, MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2012
-----------------------------------------------------
Last Update Date | 03/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 203 PARK VISTA TER
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18104-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-703-7244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 PARK VISTA TER
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18104-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-703-7244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MIRIAM SHUSTIK
-----------------------------------------------------
Credential | MD,PC
-----------------------------------------------------
Telephone | 610-703-7244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD062421L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------