1083607410 NPI number — DR. IAN M SHANTZ MD

Table of content: DR. IAN M SHANTZ MD (NPI 1083607410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083607410 NPI number — DR. IAN M SHANTZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANTZ
Provider First Name:
IAN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083607410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12622
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-481-6576
Provider Business Mailing Address Fax Number:
443-481-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 BRANDERMILL BLVD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
GAMBRILLS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21054-1690
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-721-1507
Provider Business Practice Location Address Fax Number:
410-721-1510
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  D0036203 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4668884 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9961 . This is a "KAISER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0002 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2133458 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 278331200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 609636400 . This is a "FEDERAL WORKMANS COMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2110345 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 52030309 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 218331200 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".




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