Provider Demographics
NPI:1114017084
Name:SHAW, G. LYMAN (DC, FACO)
Entity Type:Individual
Prefix:DR
First Name:G.
Middle Name:LYMAN
Last Name:SHAW
Suffix:
Gender:M
Credentials:DC, FACO
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:LYMAN
Other - Last Name:SHAW
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:DC, FACO
Mailing Address - Street 1:25 REDWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-1947
Mailing Address - Country:US
Mailing Address - Phone:317-852-5850
Mailing Address - Fax:317-852-7417
Practice Address - Street 1:17 MOTIF BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1017
Practice Address - Country:US
Practice Address - Phone:317-852-3870
Practice Address - Fax:317-852-7417
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001024111NX0800X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100133640Medicaid
IN342260Medicare ID - Type UnspecifiedMEDICARE #