1609093772 NPI number — SUSAN M SHAW FNP

Table of content: SUSAN M SHAW FNP (NPI 1609093772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609093772 NPI number — SUSAN M SHAW FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHAW HARRISON
Provider Other First Name:
SUSAN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609093772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13059
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:
04915-4021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3838 N 1ST AVE
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47710-3326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-402-8808
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2007

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: 363LF0000X , with the licence number:  71000556A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000543000 . This is a "ANTHEM PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200859330E . This is a "MEDICAID GROUP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 250470 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200406290 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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