MEDICARE: DR. MARY SHANE M.D.

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	2084P0800X	Psychiatry Physician	G32709	CA

General Provider Information

NPI Number	:	1437419140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY SHANE M.D.

Provider Business Mailing Address
First Line	:	2170 CENTURY PARK E
Second Line	:	#2111
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-2243
Country	:	US
Telephone Number	:	310-553-0981
Fax Number	:

Provider Business Practice Location Address
First Line	:	2170 CENTURY PARK E
Second Line	:	#2111
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-2243
Country	:	US
Telephone Number	:	310-553-0981
Fax Number	:

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

Provider Enumeration Date	:	05/29/2012
Last Update Date	:	05/29/2012

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