MEDICARE: ISLAND PATHOLOGY DIAGNOSTICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician

General Provider Information

NPI Number	:	1073236782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND PATHOLOGY DIAGNOSTICS

Provider Business Mailing Address
First Line	:	77A POWERHOUSE RD
Second Line	:
City	:	ROSLYN HEIGHTS
State	:	NY
Zip	:	11577-2027
Country	:	US
Telephone Number	:	917-376-5739
Fax Number	:

Provider Business Practice Location Address
First Line	:	77A POWERHOUSE RD
Second Line	:
City	:	ROSLYN HEIGHTS
State	:	NY
Zip	:	11577-2027
Country	:	US
Telephone Number	:	917-376-5739
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. SHAH MOHAMMAD GIASHUDDIN
Credential	:	MD
Telephone Number	:	917-376-5739

Provider Enumeration Date	:	09/19/2022
Last Update Date	:	09/19/2022

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