MEDICARE: MATTHEW D. SHANE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	41174	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407894850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW D. SHANE MD

Provider Business Mailing Address
First Line	:	1760 NICHOLASVILLE RD
Second Line	:	SUITE 202
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1472
Country	:	US
Telephone Number	:	859-277-5711
Fax Number	:	859-967-1769

Provider Business Practice Location Address
First Line	:	1760 NICHOLASVILLE RD
Second Line	:	SUITE 202
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1472
Country	:	US
Telephone Number	:	859-277-5711
Fax Number	:	859-967-1769

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	08/06/2015

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