Provider Demographics
NPI:1912337312
Name:FUNCTIONAL HEALTHCARE PC
Entity type:Organization
Organization Name:FUNCTIONAL HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NILAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:866-335-4040
Mailing Address - Street 1:750 RTE 34 STE 9
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-4600
Mailing Address - Country:US
Mailing Address - Phone:866-335-4040
Mailing Address - Fax:800-322-0262
Practice Address - Street 1:234 BOUNDARY RD UNIT 107
Practice Address - Street 2:
Practice Address - City:MARLBORO
Practice Address - State:NJ
Practice Address - Zip Code:07746-1479
Practice Address - Country:US
Practice Address - Phone:866-335-4040
Practice Address - Fax:800-322-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-21
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08113500207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ113615Medicare PIN