Provider Demographics
NPI:1245558493
Name:CHALYSE H. SHAW, DC, PC
Entity Type:Organization
Organization Name:CHALYSE H. SHAW, DC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHALYSE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-357-4889
Mailing Address - Street 1:PO BOX 560
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:MD
Mailing Address - Zip Code:21111-0560
Mailing Address - Country:US
Mailing Address - Phone:410-357-4889
Mailing Address - Fax:410-357-4435
Practice Address - Street 1:17112 YORK RD
Practice Address - Street 2:
Practice Address - City:PARKTON
Practice Address - State:MD
Practice Address - Zip Code:21120-9717
Practice Address - Country:US
Practice Address - Phone:410-357-4889
Practice Address - Fax:410-357-4435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01715PT261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM253CHOtherBLUE CROSS/BLUE SHIELD
MDR7290001OtherBLUECROSS/BLUECHOICE
MDU57050Medicare UPIN
MD311RMedicare PIN