Provider Demographics
NPI:1427560309
Name:SHAHBAZ RIAZ MEDICAL PC
Entity type:Organization
Organization Name:SHAHBAZ RIAZ MEDICAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHBAZ
Authorized Official - Middle Name:A
Authorized Official - Last Name:RIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-498-3792
Mailing Address - Street 1:10 KAYS POINT CT
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-4729
Mailing Address - Country:US
Mailing Address - Phone:312-498-3792
Mailing Address - Fax:573-693-1445
Practice Address - Street 1:1630 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-7929
Practice Address - Country:US
Practice Address - Phone:417-885-4700
Practice Address - Fax:417-885-4777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008022457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2008022457OtherSTATE LIC