MEDICARE: STEPHAN W SHANE D.O.

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	207R00000X	Internal Medicine Physician	036-098583	IL
2	207R00000X	Internal Medicine Physician	47019	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	019392	OTHER	CO	KAISER COMMERCIAL NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447332424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHAN W SHANE D.O.

Provider Business Mailing Address
First Line	:	859 S 4TH AVE
Second Line	:
City	:	BRIGHTON
State	:	CO
Zip	:	80601-3543
Country	:	US
Telephone Number	:	303-338-4545
Fax Number	:

Provider Business Practice Location Address
First Line	:	859 S 4TH AVE
Second Line	:
City	:	BRIGHTON
State	:	CO
Zip	:	80601-3543
Country	:	US
Telephone Number	:	303-338-4545
Fax Number	:

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

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	09/09/2011

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Directions to “ STEPHAN W SHANE D.O.” Practice Location

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