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General NPI Number Information
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NPI Number | 1962565408
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Entity Type | Organization
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Legal Business Name | JAMES SHACKSON MD
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 06/10/2008
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Provider Practice Location Address
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Address Line | 9525 KENWOOD RD SUITE 16-382
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City | CINCINNATI
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State | OH
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Zip | 45242-6176
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Country | US
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Telephone | 513-721-3504
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Fax | 513-345-6281
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Provider Business Mailing Address
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Address Line | L 6122
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City | CINCINNATI
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State | OH
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Zip | 45270-6122
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Country | US
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Telephone | 513-721-3504
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Fax | 513-345-6281
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JAMES SHACKSON
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Credential | MD
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Telephone | 513-721-3504
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0805X
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Taxonomy Name | Geriatric Psychiatry Physician
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License Number | 35062208
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License Number State | OH
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