Basic Information
Provider Information | |||||||||
NPI: | 1285772285 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NIEMANN | ||||||||
FirstName: | SHIRINE | ||||||||
MiddleName: | NASSERY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NASSERY | ||||||||
OtherFirstName: | SHIRINE | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 68 SOUTH SERVICE ROAD | ||||||||
Address2: | SUITE 350 | ||||||||
City: | MELVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 117472358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5169453000 | ||||||||
FaxNumber: | 5169453131 | ||||||||
Practice Location | |||||||||
Address1: | 71 HAYNES ST | ||||||||
Address2: |   | ||||||||
City: | MANCHESTER | ||||||||
State: | CT | ||||||||
PostalCode: | 060404131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6175956963 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2007 | ||||||||
LastUpdateDate: | 03/26/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 221648 | MA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 046540 | 01 | CT | STATE LICENSE | OTHER | 1285772285 | 05 | CT |   | MEDICAID |