Provider Demographics
NPI:1215014501
Name:SHAFFER, CHAD R (MD)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:R
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:KITTANNING
Mailing Address - State:PA
Mailing Address - Zip Code:16201-0579
Mailing Address - Country:US
Mailing Address - Phone:724-543-8164
Mailing Address - Fax:724-543-8616
Practice Address - Street 1:3615 STATE ROUTE 28 AND 66
Practice Address - Street 2:
Practice Address - City:NEW BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:16242-8107
Practice Address - Country:US
Practice Address - Phone:814-275-2264
Practice Address - Fax:814-690-7875
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013999380001Medicaid
PAMD425669OtherPA STATE LICENSE NUMBER
PASH1746844OtherPA BLUE SHIELD
PAMD425669OtherPA STATE LICENSE NUMBER
PA093294MB8Medicare ID - Type Unspecified