Healthcare Provider Details

I. General information

NPI: 1780681262
Provider Name (Legal Business Name): STEPHEN N SHOEMAKER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 E 9TH ST 1ST FLOOR
HAZLETON PA
18201-3305
US

IV. Provider business mailing address

217 E 9TH ST 1ST FLOOR
HAZLETON PA
18201-3305
US

V. Phone/Fax

Practice location:
  • Phone: 570-453-2555
  • Fax: 570-453-1043
Mailing address:
  • Phone: 570-453-2555
  • Fax: 570-453-1043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS004601-L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0010714460004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier001874
Identifier TypeOTHER
Identifier StatePA
Identifier Issuer1ST PRIORITY PROVIDER #
# 3
Identifier110160680
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRAILROAD MEDICARE #
# 4
Identifier010063200
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLACK LUNG PROVIDE #
# 5
Identifier126801
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD PROVIDER #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: