Healthcare Provider Details

I. General information

NPI: 1386617298
Provider Name (Legal Business Name): CHARLES B SHANE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 SYCAMORE HILLS CT
LOUISVILLE KY
40245-5095
US

IV. Provider business mailing address

205 SYCAMORE HILLS CT
LOUISVILLE KY
40245-5095
US

V. Phone/Fax

Practice location:
  • Phone: 502-243-8330
  • Fax: 502-243-8330
Mailing address:
  • Phone: 502-243-8330
  • Fax: 502-243-8330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: