=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972662286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTHONY SHYDOHUB MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4850 SUN N LAKE BLVD
-----------------------------------------------------
City | SEBRING
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33872-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-382-6088
-----------------------------------------------------
Fax | 863-382-9424
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4850 SUN N LAKE BLVD
-----------------------------------------------------
City | SEBRING
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33872-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-382-6088
-----------------------------------------------------
Fax | 863-382-9424
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. ANTHONY ANDREW SHYDOHUB
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 863-382-6088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | ME0061680
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------