Provider Demographics
NPI:1154338689
Name:SHORTER, IVAN COURTNEY (DO)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:COURTNEY
Last Name:SHORTER
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-733-0311
Mailing Address - Fax:717-721-5861
Practice Address - Street 1:169 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1734
Practice Address - Country:US
Practice Address - Phone:717-733-0311
Practice Address - Fax:717-721-5861
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013175207L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2119476OtherHIGHMARK BLUE SHIELD
PA102334947Medicaid
PA1584982OtherGATEWAY
PA102334947Medicaid
PAP00861177Medicare PIN
PA1584982OtherGATEWAY