Provider Demographics
NPI:1386617298
Name:SHANE, CHARLES B (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
Last Name:SHANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:205 SYCAMORE HILLS CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5095
Mailing Address - Country:US
Mailing Address - Phone:502-243-8330
Mailing Address - Fax:502-243-8330
Practice Address - Street 1:205 SYCAMORE HILLS CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-5095
Practice Address - Country:US
Practice Address - Phone:502-243-8330
Practice Address - Fax:502-243-8330
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY18903207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000068700OtherANTHEM
KY64189038Medicaid
406163932Medicare PIN
KY1209501Medicare PIN
KYC71599Medicare UPIN
KY$$$$$$$$$Medicare PIN