1205841491 NPI number — BRIAN J SHAHEEN MD

Table of content: BRIAN J SHAHEEN MD (NPI 1205841491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205841491 NPI number — BRIAN J SHAHEEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAHEEN
Provider First Name:
BRIAN
Provider Middle Name:
J
Provider Name Prefix Text:
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:
1205841491
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2699
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32513-2699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-475-4686
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2421 THOMAS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PANAMA CITY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32408-5808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-770-3240
Provider Business Practice Location Address Fax Number:
850-770-3245
Provider Enumeration Date:
07/29/2006

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:  ME63221 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 371410004 . This is a "COMMERCIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 036097648 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104128400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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