Healthcare Provider Details

I. General information

NPI: 1073786521
Provider Name (Legal Business Name): SHANE A GAILUSHAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2008
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MERCY EAR NOSE AND THROAT CLINIC 901 8TH AVENUE SE
CEDAR RAPIDS IA
52401
US

IV. Provider business mailing address

MERCY EAR NOSE AND THROAT CLINIC 901 8TH AVENUE SE
CEDAR RAPIDS IA
52401
US

V. Phone/Fax

Practice location:
  • Phone: 319-398-6900
  • Fax: 319-398-6901
Mailing address:
  • Phone: 319-398-6900
  • Fax: 319-398-6901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMD-43426
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMED-PHYS-LIC-33185
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number53757-20
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number2013015482
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMD2015-0203
License Number StateNM
# 6
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number8995595-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: