Provider Demographics
NPI:1871901298
Name:GLEN OAK MEDICAL CARE PLLC
Entity type:Organization
Organization Name:GLEN OAK MEDICAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAIRA
Authorized Official - Middle Name:KHALID
Authorized Official - Last Name:SHAHAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-270-4729
Mailing Address - Street 1:126 BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2320
Mailing Address - Country:US
Mailing Address - Phone:516-270-4729
Mailing Address - Fax:
Practice Address - Street 1:26205 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11004-1756
Practice Address - Country:US
Practice Address - Phone:516-270-4729
Practice Address - Fax:516-833-7470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230853-1207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02743593Medicaid
NY02743593Medicaid