1508015207 NPI number — FAWAD A. SHAHEEN MD

Table of content: FAWAD A. SHAHEEN MD (NPI 1508015207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508015207 NPI number — FAWAD A. SHAHEEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAHEEN
Provider First Name:
FAWAD
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508015207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 636256 CENTRAL CREDENTIALING
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-585-5504
Provider Business Mailing Address Fax Number:
513-585-5511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 31ST ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33712-1419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-289-7139
Provider Business Practice Location Address Fax Number:
727-289-7140
Provider Enumeration Date:
09/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  MD2022-1142 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: ME111493 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HP383U . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112026300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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