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General NPI Number Information
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NPI Number | 1285736462
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Entity Type | Individual
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Provider Name | SHANE TIMOTHY DESIMONE MD
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Gender | Male
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Dates
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Enumeration Date | 09/01/2006
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Last Update Date | 12/20/2011
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Provider Practice Location Address
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Address Line | 202-206 MILBY STREET
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City | GREENSBURG
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State | KY
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Zip | 42743
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Country | US
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Telephone | 270-932-4211
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Fax | 270-299-2041
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Provider Business Mailing Address
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Address Line | PO BOX 220
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City | GREENSBURG
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State | KY
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Zip | 42743-0220
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Country | US
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Telephone | 270-932-4211
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Fax | 270-299-2041
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | T2005018779
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 43280
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License Number State | KY
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