Healthcare Provider Details

I. General information

NPI: 1023396769
Provider Name (Legal Business Name): SHANE M HUCH D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 NJ-138 SUITE 101
WALL NJ
07719
US

IV. Provider business mailing address

1 MEDICAL CENTER DR DHMC DEPARTMENT OF PAIN MEDICINE
LEBANON NH
03756-1000
US

V. Phone/Fax

Practice location:
  • Phone: 732-747-7077
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number26389-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number25MB09454300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: