Healthcare Provider Details

I. General information

NPI: 1093997645
Provider Name (Legal Business Name): SHANE D HEMPHILL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 AVENT FERRY RD STE 310
HOLLY SPRINGS NC
27540-7776
US

IV. Provider business mailing address

2000 PERIMETER PARK DR STE 200
MORRISVILLE NC
27560-8442
US

V. Phone/Fax

Practice location:
  • Phone: 919-552-8914
  • Fax: 919-552-8955
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME102888
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberP19555
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2011-01595
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: