MEDICARE: JONATHAN SHACK MD

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	MD045140L	PA

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

General Provider Information

NPI Number	:	1629066626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN SHACK MD

Provider Business Mailing Address
First Line	:	3425 N CARLISLE ST
Second Line	:	2ND FLOOR HUDSON BLDG
City	:	PHILADELPHIA
State	:	PA
Zip	:	19140-5108
Country	:	US
Telephone Number	:	215-707-4739
Fax Number	:	215-707-3677

Provider Business Practice Location Address
First Line	:	100 E LEHIGH AVE
Second Line	:	MAB BLDG STE 105
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-1000
Country	:	US
Telephone Number	:	215-707-8496
Fax Number	:	215-707-4086

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

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	07/08/2007

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