MEDICARE: DR. IAN M SHANTZ MD

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	207Q00000X	Family Medicine Physician	D0036203	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	4668884	OTHER	AETNA PPO
2	9961	OTHER	KAISER
3	0002	OTHER	BCBS
4	2133458	OTHER	MAMSI
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	609636400	OTHER	FEDERAL WORKMANS COMP
7	2110345	OTHER	AETNA HMO
8	52030309	OTHER	BCBS
9	218331200	OTHER	AMERIGROUP

General Provider Information

NPI Number	:	1083607410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IAN M SHANTZ MD

Provider Business Mailing Address
First Line	:	PO BOX 12622
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-4017
Country	:	US
Telephone Number	:	443-481-6576
Fax Number	:	443-481-6515

Provider Business Practice Location Address
First Line	:	2401 BRANDERMILL BLVD
Second Line	:	SUITE 250
City	:	GAMBRILLS
State	:	MD
Zip	:	21054-1690
Country	:	US
Telephone Number	:	410-721-1507
Fax Number	:	410-721-1510

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

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	11/29/2013

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Directions to “ DR. IAN M SHANTZ MD” Practice Location

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