Healthcare Provider Details

I. General information

NPI: 1801045133
Provider Name (Legal Business Name): BRIAN W SHIPPERT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E PARK AVE
STATE COLLEGE PA
16803-6709
US

IV. Provider business mailing address

1800 E PARK AVE
STATE COLLEGE PA
16803-6709
US

V. Phone/Fax

Practice location:
  • Phone: 814-278-4818
  • Fax: 814-234-6150
Mailing address:
  • Phone: 814-278-4818
  • Fax: 814-234-6150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberOS014818
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2010-00473
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS11793
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102203823
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS014818
License Number StatePA
# 6
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036155857
License Number StateIL

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: