MEDICARE: EMERALD BAY CENTER FOR WOMEN'S HEALTH, INC.

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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1164679940
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD BAY CENTER FOR WOMEN'S HEALTH, INC.

Provider Business Mailing Address
First Line	:	1154 EMERALD BAY RD
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-6288
Country	:	US
Telephone Number	:	530-542-4961
Fax Number	:	530-542-4964

Provider Business Practice Location Address
First Line	:	1154 EMERALD BAY RD
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-6288
Country	:	US
Telephone Number	:	530-542-4961
Fax Number	:	530-542-4964

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	DR. M. KELLY SHANAHAN
Credential	:	MD
Telephone Number	:	530-542-4961

Provider Enumeration Date	:	08/22/2008
Last Update Date	:	07/30/2013

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