Provider Demographics
NPI:1063557866
Name:MCSHANE SPORTS MEDICINE PC
Entity type:Organization
Organization Name:MCSHANE SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCSHANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-254-8001
Mailing Address - Street 1:734 E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:VILLANOVA
Mailing Address - State:PA
Mailing Address - Zip Code:19085-1325
Mailing Address - Country:US
Mailing Address - Phone:610-254-8001
Mailing Address - Fax:610-254-0911
Practice Address - Street 1:734 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:VILLANOVA
Practice Address - State:PA
Practice Address - Zip Code:19085-1325
Practice Address - Country:US
Practice Address - Phone:610-254-8001
Practice Address - Fax:610-254-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
906548OtherHIGHMARK BS
906548OtherHIGHMARK BS