=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629066626
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN SHACK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E LEHIGH AVE MAB BLDG STE 105
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19125-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-707-8496
-----------------------------------------------------
Fax | 215-707-4086
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3425 N CARLISLE ST 2ND FLOOR HUDSON BLDG
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19140-5108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-707-4739
-----------------------------------------------------
Fax | 215-707-3677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD045140L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------