Healthcare Provider Details

I. General information

NPI: 1114912151
Provider Name (Legal Business Name): JILL SHANK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LUIGINA SHANK MD

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E ANTIETAM ST
HAGERSTOWN MD
21740
US

IV. Provider business mailing address

PO BOX 1248
HAGERSTOWN MD
21740-1248
US

V. Phone/Fax

Practice location:
  • Phone: 301-790-8501
  • Fax:
Mailing address:
  • Phone: 800-938-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD47458
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: