MEDICARE: DR. SHANTHA GANESAN MD

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	214120-1	NY
2	207L00000X	Anesthesiology Physician	214120-1	NY

General Provider Information

NPI Number	:	1457323859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANTHA GANESAN MD

Provider Business Mailing Address
First Line	:	22303 KINGSBURY AVE
Second Line	:	BAYSIDE
City	:	OAKLAND GARDENS
State	:	NY
Zip	:	11364-3602
Country	:	US
Telephone Number	:	718-776-3090
Fax Number	:	718-245-5544

Provider Business Practice Location Address
First Line	:	451 CLARKSON AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-2054
Country	:	US
Telephone Number	:	718-245-4409
Fax Number	:	718-245-5544

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	10/22/2019

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