MEDICARE: JAMES B SHACKSON 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	EMC0005754	MI
2	2084P0800X	Psychiatry Physician	01045038A	IN
3	2084P0800X	Psychiatry Physician	04-52327	KS
4	2084P0800X	Psychiatry Physician	67932	TN
5	2084P0800X	Psychiatry Physician	MD487198C	PA
6	2084P0800X	Psychiatry Physician	35-062208	OH
7	2084P0800X	Psychiatry Physician	C1406	KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DF6496	OTHER	OH	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831185545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES B SHACKSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 11167
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46856-1167
Country	:	US
Telephone Number	:	574-546-1900
Fax Number	:	574-546-1999

Provider Business Practice Location Address
First Line	:	21 E STATE ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43215-4281
Country	:	US
Telephone Number	:	574-546-1900
Fax Number	:	574-546-1999

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

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	01/16/2026

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