Provider Demographics
NPI:1588613780
Name:YORK, SHANE MYLES (DPM)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:MYLES
Last Name:YORK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 MIDLANDS CT
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3125
Mailing Address - Country:US
Mailing Address - Phone:815-758-0000
Mailing Address - Fax:815-756-7130
Practice Address - Street 1:2111 MIDLANDS CT
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3125
Practice Address - Country:US
Practice Address - Phone:815-758-0000
Practice Address - Fax:815-756-7130
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-189213ES0103X
IL016-005300213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL119909OtherHEALTH ALLIANCE IDENTIFIE
IL1915167OtherBLUECROSSBLUE SHIELD
IL016005300Medicaid
IL03595800001OtherDMERC IDENTIFIER
IL016005300Medicaid
IL119909OtherHEALTH ALLIANCE IDENTIFIE