Provider Demographics
NPI:1083000541
Name:ROTHERMEL, SHANE (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:ROTHERMEL
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 1:2500 ENGLISH CREEK AVE STE 1300
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-5598
Mailing Address - Country:US
Mailing Address - Phone:609-677-7013
Mailing Address - Fax:609-677-7000
Practice Address - Street 1:3676 PARKER BLVD STE 390
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2215
Practice Address - Country:US
Practice Address - Phone:719-595-7780
Practice Address - Fax:719-595-7789
Is Sole Proprietor?:No
Enumeration Date:2015-04-11
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10759000207XS0114X
PAMD462106207XS0114X
390200000X
CODR0065962207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program