Healthcare Provider Details

I. General information

NPI: 1326083379
Provider Name (Legal Business Name): THOMAS SHAUGHNESSY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 THOMAS MORE PKWY STE 202
EDGEWOOD KY
41017-5103
US

IV. Provider business mailing address

4600 MONTGOMERY RD STE 105
CINCINNATI OH
45212-2697
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-6281
  • Fax: 859-341-4661
Mailing address:
  • Phone: 513-487-5305
  • Fax: 513-487-5317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number35-053140
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number21833
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01034872
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: