MEDICARE: DR. SHAN PSYCHIATRY CLINIC LLC

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	103G00000X	Clinical Neuropsychologist	MD421627	PA

General Provider Information

NPI Number	:	1861637381
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. SHAN PSYCHIATRY CLINIC LLC

Provider Business Mailing Address
First Line	:	756 ADAMS AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-2330
Country	:	US
Telephone Number	:	215-533-3660
Fax Number	:	215-533-3682

Provider Business Practice Location Address
First Line	:	756 ADAMS AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-2330
Country	:	US
Telephone Number	:	215-533-3660
Fax Number	:	215-533-3682

Authorized Official
Title or Position	:	DIRECTOR
Name	:	YANG SHAN
Credential	:	M.D.
Telephone Number	:	215-533-3660

Provider Enumeration Date	:	12/12/2008
Last Update Date	:	12/12/2008

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