Provider Demographics
NPI:1962525402
Name:ROCKCASTLE VENTURES INC. D.B.A. CALLIE SHAFFER, M.D.
Entity type:Organization
Organization Name:ROCKCASTLE VENTURES INC. D.B.A. CALLIE SHAFFER, M.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-256-7761
Mailing Address - Street 1:PO BOX 1525
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456-1525
Mailing Address - Country:US
Mailing Address - Phone:606-256-4148
Mailing Address - Fax:
Practice Address - Street 1:140 NEWCOMB AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456-2728
Practice Address - Country:US
Practice Address - Phone:606-256-4148
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65942690Medicaid