MEDICARE: DR. SHANE M BEZZANT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	01058636A	IN
2	2085R0202X	Diagnostic Radiology Physician	50862	AZ

General Provider Information

NPI Number	:	1033190202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANE M BEZZANT M.D.

Provider Business Mailing Address
First Line	:	PO BOX 33269
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85067-3269
Country	:	US
Telephone Number	:	602-406-4786
Fax Number	:	916-636-4358

Provider Business Practice Location Address
First Line	:	350 W THOMAS RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85013-4409
Country	:	US
Telephone Number	:	602-406-3430
Fax Number	:	602-406-2340

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	10/24/2024

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