MEDICARE: DR. CHARLES D. SHOOK 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	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	35.028399	OH

General Provider Information

NPI Number	:	1457797847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES D. SHOOK M. D.

Provider Business Mailing Address
First Line	:	718 GLENDALE BLVD
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44907-2226
Country	:	US
Telephone Number	:	419-756-9404
Fax Number	:

Provider Business Practice Location Address
First Line	:	718 GLENDALE BLVD
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44907-2226
Country	:	US
Telephone Number	:	419-756-9404
Fax Number	:

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

Provider Enumeration Date	:	05/13/2013
Last Update Date	:	05/13/2013

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