Provider Demographics
NPI:1497820336
Name:SHENK, IAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:M
Last Name:SHENK
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 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:PPQA MEDICARE COMPLIANCE UNIT 6 WEST
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:6501 LOISDALE COURT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-1885
Practice Address - Country:US
Practice Address - Phone:703-922-1407
Practice Address - Fax:703-922-1111
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101021688163WG0100X
MDD009315207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WG0100XNursing Service ProvidersRegistered NurseGastroenterology
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
015885K92Medicare ID - Type Unspecified
B93465Medicare UPIN