Basic Information
Provider Information | |||||||||
NPI: | 1972579621 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FISCH | ||||||||
FirstName: | SHIRLEY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8000 | ||||||||
Address2: | DEPT 596 | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142670002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8662950041 | ||||||||
FaxNumber: | 7083422517 | ||||||||
Practice Location | |||||||||
Address1: | 300 2ND AVE | ||||||||
Address2: |   | ||||||||
City: | LONG BRANCH | ||||||||
State: | NJ | ||||||||
PostalCode: | 077406303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7329237790 | ||||||||
FaxNumber: | 7329237722 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2006 | ||||||||
LastUpdateDate: | 02/13/2013 | ||||||||
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 | 2084N0402X | 25MA07978600 | NJ | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
ID | Type | State | Issuer | Description | 2776539000 | 01 | NJ | AMERIHEALTH | OTHER | 60037643 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 9107622 | 01 | NJ | CIGNA | OTHER | 7138088 | 01 | NJ | AETNA | OTHER | 223316007-093 | 01 | NJ | QUALCARE | OTHER | 0150975 | 05 | NJ |   | MEDICAID | 223316007P | 01 | NJ | HORIZON BC BS | OTHER | 3K7753 | 01 | NJ | HEALTHNET | OTHER |