Healthcare Provider Details

I. General information

NPI: 1831143361
Provider Name (Legal Business Name): MCSHANE SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 E LANCASTER AVE
VILLANOVA PA
19085-1325
US

IV. Provider business mailing address

734 E LANCASTER AVE
VILLANOVA PA
19085-1325
US

V. Phone/Fax

Practice location:
  • Phone: 610-254-8001
  • Fax: 610-254-0911
Mailing address:
  • Phone: 610-254-8001
  • Fax: 610-254-0911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD055461L
License Number StatePA

VIII. Authorized Official

Name: DR. JOHN M MCSHANE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 610-254-8001