Provider Demographics
NPI:1205816014
Name:SHOCKLEY, ALBEN B (MD)
Entity Type:Individual
Prefix:
First Name:ALBEN
Middle Name:B
Last Name:SHOCKLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2211 MAYFAIR DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-4568
Mailing Address - Country:US
Mailing Address - Phone:270-688-1352
Mailing Address - Fax:270-683-4313
Practice Address - Street 1:2211 MAYFAIR DR
Practice Address - Street 2:SUITE 101
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4568
Practice Address - Country:US
Practice Address - Phone:270-688-1352
Practice Address - Fax:270-683-4313
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY26126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6426126600Medicaid
KY000000049664OtherBCBS PIN #
IN100224950Medicaid
KYE35199Medicare UPIN
IN100224950Medicaid
KY3397701Medicare PIN
KYM400030929Medicare PIN