MEDICARE: DR. LYDIA SHAJENKO M.D.

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	2084N0400X	Neurology Physician	216559	NY
2	2084N0600X	Clinical Neurophysiology Physician	25MA08061700	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841289634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYDIA SHAJENKO M.D.

Provider Business Mailing Address
First Line	:	725 RIVER RD STE 55
Second Line	:
City	:	EDGEWATER
State	:	NJ
Zip	:	07020-1121
Country	:	US
Telephone Number	:	646-712-1635
Fax Number	:	866-267-8173

Provider Business Practice Location Address
First Line	:	725 RIVER RD STE 55
Second Line	:
City	:	EDGEWATER
State	:	NJ
Zip	:	07020-1121
Country	:	US
Telephone Number	:	646-712-1635
Fax Number	:	866-267-8173

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

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	10/26/2017

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