Basic Information
| Provider Information | |||||||||
| NPI: | 1447244173 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FERESHETIAN | ||||||||
| FirstName: | SHAHE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | SUITE 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5084386364 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MOUNT AUBURN ST | ||||||||
| Address2: | SUITE 510S | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021385600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173544584 | ||||||||
| FaxNumber: | 6174917735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 06/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 71442 | MA | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3050769 | 05 | MA | MEDICAID |