Basic Information
| Provider Information | |||||||||
| NPI: | 1477577526 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISLAM | ||||||||
| FirstName: | SHAIFUL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7177096529 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 ST PAUL DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172176955 | ||||||||
| FaxNumber: | 7172176955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0901X | 213878 | NY | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207R00000X | MD419346 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 213878 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | MD419346 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 02010731 | 05 | NY | MEDICAID | 867633 | 01 | PA | MEDICARE GROUP # | OTHER | 102183950 0001 | 05 | PA | MEDICAID | 1007307260040 | 01 | PA | MEDICAID GROUP # | OTHER |