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General NPI Number Information
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NPI Number | 1215067780
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Entity Type | Organization
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Legal Business Name | CHARLES B SHANE MD PSC
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 02/24/2009
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Provider Practice Location Address
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Address Line | 4001 KRESGE WAY SUITE 315
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City | LOUISVILLE
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State | KY
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Zip | 40207-4640
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Country | US
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Telephone | 502-895-7445
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Fax | 502-895-6638
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Provider Business Mailing Address
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Address Line | 4001 KRESGE WAY SUITE 315
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City | LOUISVILLE
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State | KY
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Zip | 40207-4640
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Country | US
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Telephone | 502-895-7445
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Fax | 502-895-6638
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Authorized Official
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Title or Position | OWNER PHYSICIAN
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Name | CHARLES B SHANE
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Credential | MD
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Telephone | 502-895-7445
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | 18903
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License Number State | KY
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