Advanced Internal Medicine, P.C.
Organization Active NPI Internal Medicine Physician · Great Neck, NY
NPI 1467709451 · NPPES record last updated Nov 28, 2018
Key facts
- NPI
- 1467709451
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Internal Medicine Physician 207R00000X
- License
- 236142 (NY)
- Legal business name
- ADVANCED INTERNAL MEDICINE, P.C.
- Practice address
- 935 Northern Blvd Ste 105
Great Neck, NY 11021-5309 - Phone
- (516) 487-0070
- Fax
- (516) 487-0072
- NPI assigned
- Aug 8, 2012
- Organization subpart
- No
Authorized official
- Name
- Dr. Shahram Daniel Shamekh, M.D.
- Title
- President/Ceo
- Phone
- (516) 455-7017
Practitioners 2
-
Shahram Hormozi, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 33D2068454 | Advanced Internal Medicine, PC | Certificate of waiver | May 31, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NY
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20130418000341 | NY | Part B Supplier - Clinic/Group Practice | 5294971230 |
Receives reassigned benefits from 2 practitioners Practice locations: Great Neck, NY |
National Provider Directory
Locations
935 Northern Blvd
Ste 105
Great Neck, NY 11021
Phone (516) 487-0070
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician |
207R00000X | 236142 | NY | Yes |
Addresses
Primary practice location
935 Northern Blvd Ste 105
Great Neck, NY 11021-5309
Mailing address
130 Gristmill LN
Great Neck, NY 11023-1839
Phone (516) 455-7017
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 02708294 | Medicaid | NY |
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All providers in Great Neck, NY · Internal Medicine Physician in New York
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 28, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.