Provider Demographics
NPI:1225127954
Name:SHAW, ALBERT BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:BRIAN
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 BLUEBELL TRL
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-5215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1626 BLUEBELL TRL
Practice Address - Street 2:
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-5215
Practice Address - Country:US
Practice Address - Phone:330-000-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0939892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100160740Medicaid
OH2973617Medicaid
KS100160740Medicaid
OH2973617Medicaid
OH4267773Medicare PIN
KS046798Medicare PIN
OH4267771Medicare PIN