Provider Demographics
NPI:1154627867
Name:SHAWN T. EGAN, PA
Entity Type:Organization
Organization Name:SHAWN T. EGAN, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:T
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, PA
Authorized Official - Phone:321-254-3630
Mailing Address - Street 1:1310 W EAU GALLIE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5300
Mailing Address - Country:US
Mailing Address - Phone:321-254-3630
Mailing Address - Fax:321-242-8176
Practice Address - Street 1:1310 W EAU GALLIE BLVD STE A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5300
Practice Address - Country:US
Practice Address - Phone:321-254-3630
Practice Address - Fax:321-242-8176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4130111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380033400Medicaid
FL70718OtherBLUE CROSS AND BLUE SHIELD
FL380033400Medicaid