1083014302 NPI number — TIFFANY MARIE SHADER PHD

Table of content: TIFFANY MARIE SHADER PHD (NPI 1083014302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083014302 NPI number — TIFFANY MARIE SHADER PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHADER
Provider First Name:
TIFFANY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

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:
1083014302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4100 HORIZONS DR.
Provider Second Line Business Mailing Address:
STE 202, OFFICE 203
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43220-5280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-357-7810
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4100 HORIZONS DR.
Provider Second Line Business Practice Location Address:
STE 202, OFFICE 203
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-355-8160
Provider Business Practice Location Address Fax Number:
614-355-8180
Provider Enumeration Date:
08/25/2014

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: 103T00000X , with the licence number:  32997 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: P.08452 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2846675 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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