Healthcare Provider Details

I. General information

NPI: 1205889748
Provider Name (Legal Business Name): AL M SHANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

801 BROADWAY N
FARGO ND
58102-3641
US

V. Phone/Fax

Practice location:
  • Phone: 701-781-3444
  • Fax:
Mailing address:
  • Phone: 701-781-3444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number35099267
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number35099267
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number10140
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0065902
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 2
Identifier7100146510
Identifier TypeMEDICAID
Identifier StateKY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: