Healthcare Provider Details

I. General information

NPI: 1750426730
Provider Name (Legal Business Name): CHARLES H. SHAW, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 CLINE AVE
MANSFIELD OH
44907-1057
US

IV. Provider business mailing address

370 CLINE AVE
MANSFIELD OH
44907-1057
US

V. Phone/Fax

Practice location:
  • Phone: 419-756-8511
  • Fax: 419-756-8513
Mailing address:
  • Phone: 419-756-8511
  • Fax: 419-756-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateOH

VIII. Authorized Official

Name: CHARLES H. SHAW
Title or Position: OWNER
Credential: M.D.
Phone: 419-756-8511