Healthcare Provider Details

I. General information

NPI: 1558363085
Provider Name (Legal Business Name): MARK P SHAMPAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 COLLEGE HEIGHTS BLVD STE 200
ALLENTOWN PA
18104-4812
US

IV. Provider business mailing address

3131 COLLEGE HEIGHTS BLVD STE 200
ALLENTOWN PA
18104-4812
US

V. Phone/Fax

Practice location:
  • Phone: 610-820-7611
  • Fax: 610-820-9884
Mailing address:
  • Phone: 610-820-7611
  • Fax: 610-820-9884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberMD025134E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: