MEDICARE: MS. LESLEA ANN SHAMP PT

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	174400000X	Specialist	PTH1047	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51515971	OTHER	AL	BCBS AL
2	7333487	OTHER	AL	AETNA

General Provider Information

NPI Number	:	1073516506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LESLEA ANN SHAMP PT

Provider Business Mailing Address
First Line	:	2204 LAKESHORE DR
Second Line	:	STE 150
City	:	HOMEWOOD
State	:	AL
Zip	:	35209-6729
Country	:	US
Telephone Number	:	205-423-9502
Fax Number	:	205-423-9504

Provider Business Practice Location Address
First Line	:	2204 LAKESHORE DR
Second Line	:	STE 150
City	:	HOMEWOOD
State	:	AL
Zip	:	35209-6729
Country	:	US
Telephone Number	:	205-423-9502
Fax Number	:	205-423-9504

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

Provider Enumeration Date	:	05/30/2005
Last Update Date	:	12/08/2008

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