Provider Demographics
NPI:1164545620
Name:SHANE C HERNESMAN MD PA
Entity Type:Organization
Organization Name:SHANE C HERNESMAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HERNESMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-631-4940
Mailing Address - Street 1:505 DELANNOY AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7813
Mailing Address - Country:US
Mailing Address - Phone:321-631-4940
Mailing Address - Fax:321-631-4941
Practice Address - Street 1:505 DELANNOY AVE
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7813
Practice Address - Country:US
Practice Address - Phone:321-631-4940
Practice Address - Fax:321-631-4941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG83792Medicare UPIN