Healthcare Provider Details

I. General information

NPI: 1215067780
Provider Name (Legal Business Name): CHARLES B SHANE MD PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 KRESGE WAY SUITE 315
LOUISVILLE KY
40207-4640
US

IV. Provider business mailing address

4001 KRESGE WAY SUITE 315
LOUISVILLE KY
40207-4640
US

V. Phone/Fax

Practice location:
  • Phone: 502-895-7445
  • Fax: 502-895-6638
Mailing address:
  • Phone: 502-895-7445
  • Fax: 502-895-6638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number18903
License Number StateKY

VIII. Authorized Official

Name: CHARLES B SHANE
Title or Position: OWNER PHYSICIAN
Credential: MD
Phone: 502-895-7445