Provider Demographics
NPI:1497736441
Name:FERNANDES, KARL SHANE (MD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:SHANE
Last Name:FERNANDES
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 1:1661 HOLLAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537
Mailing Address - Country:US
Mailing Address - Phone:419-843-7800
Mailing Address - Fax:419-843-3444
Practice Address - Street 1:1661 HOLLAND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537
Practice Address - Country:US
Practice Address - Phone:419-843-7800
Practice Address - Fax:419-843-3444
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072158F207RC0200X, 207RP1001X
OH35072158207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2032286Medicaid
OH81000658OtherMEDICARE RAILROAD
OH2032286Medicaid
OHG22748Medicare UPIN
OH0828207Medicare PIN
OH0828204Medicare PIN
OH0828202Medicare PIN