MEDICARE: JONATHAN NEIL SHENK 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	207P00000X	Emergency Medicine Physician	01060154	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00238236	OTHER	IN	RAIL ROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000000361760	OTHER	IN	ANTHEM
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164422002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN NEIL SHENK MD

Provider Business Mailing Address
First Line	:	5215 HOLY CROSS PKWY
Second Line	:	EMERGENCY DEPARTMENT
City	:	MISHAWAKA
State	:	IN
Zip	:	46545-1469
Country	:	US
Telephone Number	:	574-335-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5215 HOLY CROSS PKWY
Second Line	:	EMERGENCY DEPARTMENT
City	:	MISHAWAKA
State	:	IN
Zip	:	46545-1469
Country	:	US
Telephone Number	:	574-335-5000
Fax Number	:

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

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	12/16/2011

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