Provider Demographics
NPI:1154490746
Name:DAVID E. SHANKS, PA
Entity Type:Organization
Organization Name:DAVID E. SHANKS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:SHANKS
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:704-364-6676
Mailing Address - Street 1:3717 LATROBE DR STE 750
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4826
Mailing Address - Country:US
Mailing Address - Phone:704-364-6676
Mailing Address - Fax:704-364-1358
Practice Address - Street 1:3717 LATROBE DR STE 750
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4826
Practice Address - Country:US
Practice Address - Phone:704-364-6676
Practice Address - Fax:704-364-1358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8975428Medicaid
NC406291010OtherPALMETTO GBA RR MEDICARE
NC30596OtherMEDCOST
NC75428OtherBLUE CROSS
NC30596OtherMEDCOST
NC=========OtherCIGNA HEALTHCARE
NC=========OtherUNITED HEALTHCARE
NC406291010OtherPALMETTO GBA RR MEDICARE