1215067780 NPI number — CHARLES B SHANE MD PSC

Table of content: (NPI 1215067780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215067780 NPI number — CHARLES B SHANE MD PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES B SHANE MD PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1215067780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4001 KRESGE WAY
Provider Second Line Business Mailing Address:
SUITE 315
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40207-4640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-895-7445
Provider Business Mailing Address Fax Number:
502-895-6638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4001 KRESGE WAY
Provider Second Line Business Practice Location Address:
SUITE 315
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-895-7445
Provider Business Practice Location Address Fax Number:
502-895-6638
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHANE
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
502-895-7445

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  18903 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 64189038 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000068700 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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