Provider Demographics
NPI:1407894850
Name:SHANE, MATTHEW D (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:SHANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 NICHOLASVILLE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1472
Mailing Address - Country:US
Mailing Address - Phone:859-277-5711
Mailing Address - Fax:859-967-1769
Practice Address - Street 1:1760 NICHOLASVILLE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1472
Practice Address - Country:US
Practice Address - Phone:859-277-5711
Practice Address - Fax:859-967-1769
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY41174208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100018900Medicaid
KYP00439243Medicare PIN
KY0542810Medicare PIN
KY7100018900Medicaid