MEDICARE: SHANE C HERNESMAN MD PA

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	ME83457	FL

General Provider Information

NPI Number	:	1164545620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANE C HERNESMAN MD PA

Provider Business Mailing Address
First Line	:	505 DELANNOY AVE
Second Line	:
City	:	COCOA
State	:	FL
Zip	:	32922-7813
Country	:	US
Telephone Number	:	321-631-4940
Fax Number	:	321-631-4941

Provider Business Practice Location Address
First Line	:	505 DELANNOY AVE
Second Line	:
City	:	COCOA
State	:	FL
Zip	:	32922-7813
Country	:	US
Telephone Number	:	321-631-4940
Fax Number	:	321-631-4941

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SHANE C HERNESMAN
Credential	:	MD
Telephone Number	:	321-631-4940

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	08/22/2020

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