Provider Demographics
NPI: | 1003836412 |
---|---|
Name: | SHULL, EMILY R (OD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | EMILY |
Middle Name: | R |
Last Name: | SHULL |
Suffix: | |
Gender: | F |
Credentials: | OD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1945 CEI DRIVE |
Mailing Address - Street 2: | |
Mailing Address - City: | CINCINNATI |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45242-3311 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 513-984-5133 |
Mailing Address - Fax: | 859-331-9040 |
Practice Address - Street 1: | 580 S LOOP RD |
Practice Address - Street 2: | SUITE 200 |
Practice Address - City: | EDGEWOOD |
Practice Address - State: | KY |
Practice Address - Zip Code: | 41017-3405 |
Practice Address - Country: | US |
Practice Address - Phone: | 859-331-9000 |
Practice Address - Fax: | 859-331-9040 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-20 |
Last Update Date: | 2007-12-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 5574 T2488 | 152W00000X |
KY | 1681DT | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 1406827 | Medicaid | |
KY | P00405513 | Other | RAILROAD MEDICARE |
OH | 2699567 | Medicaid | |
000000484330 | Other | BCBS FACET | |
OH | 1406827 | Medicaid | |
KY | 0656019 | Medicare PIN | |
OH | 4174462 | Medicare PIN |