Healthcare Provider Details

I. General information

NPI: 1083000541
Provider Name (Legal Business Name): SHANE ROTHERMEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2015
Last Update Date: 10/30/2021
Certification Date: 10/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3676 PARKER BLVD STE 390
PUEBLO CO
81008-2215
US

IV. Provider business mailing address

2500 ENGLISH CREEK AVE STE 1300
EGG HARBOR TOWNSHIP NJ
08234-5598
US

V. Phone/Fax

Practice location:
  • Phone: 719-595-7780
  • Fax: 719-595-7789
Mailing address:
  • Phone: 609-677-7013
  • Fax: 609-677-7000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number25MA10759000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberMD462106
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberDR0065962
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: