Healthcare Provider Details

I. General information

NPI: 1689667578
Provider Name (Legal Business Name): STEVEN SHANE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 CHESTNUT STREET
UNION NJ
07083-7951
US

IV. Provider business mailing address

PO BOX 417012
BOSTON MA
02241-7012
US

V. Phone/Fax

Practice location:
  • Phone: 908-851-8346
  • Fax:
Mailing address:
  • Phone: 201-487-7227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number25MB03653600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: