Provider Demographics
NPI:1629042197
Name:SHAW, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:SHAW
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-584-3377
Mailing Address - Fax:502-584-1385
Practice Address - Street 1:220 ABRAHAM FLEXNER WAY
Practice Address - Street 2:SUITE 1100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3826
Practice Address - Country:US
Practice Address - Phone:502-584-3377
Practice Address - Fax:502-584-1385
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035377A207X00000X, 208100000X
KY24102207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000048660OtherANTHEM
KY1050654OtherPASSPORT
KY2432935000OtherPASSPORT ADVANTAGE
KY250002297OtherKY RAILROAD MEDICARE
KY61-1086535OtherTAX ID
KY64241029Medicaid
IN100359260Medicaid
INP00003389OtherIND RAILROAD MEDICARE
KY2432935000OtherPASSPORT ADVANTAGE
KY1050654OtherPASSPORT
KY0078106Medicare PIN