=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942695531
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ISAAC SHAW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2015
-----------------------------------------------------
Last Update Date | 07/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 530 S JACKSON ST
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-1675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-852-5689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 231 ALBERT SABIN WAY MSB 1654
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45267-0769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-558-8114
-----------------------------------------------------
Fax | 513-558-5791
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 57.026084
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 52410
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------