Healthcare Provider Details

I. General information

NPI: 1750763397
Provider Name (Legal Business Name): SHANE P MCTIGHE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 BROOKSTONE CENTRE PKWY
COLUMBUS GA
31904-9272
US

IV. Provider business mailing address

1210 BROOKSTONE CENTRE PKWY
COLUMBUS GA
31904-9272
US

V. Phone/Fax

Practice location:
  • Phone: 706-322-1717
  • Fax: 706-322-1718
Mailing address:
  • Phone: 706-322-1717
  • Fax: 706-322-1718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number93963
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: