Provider Demographics
NPI:1669474805
Name:SHAWCHUCK, KAY MARIE (MD)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:MARIE
Last Name:SHAWCHUCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAY
Other - Middle Name:MARIE
Other - Last Name:ABDULLAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 25317
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-5317
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:6450 38TH AVE N STE 440
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1653
Practice Address - Country:US
Practice Address - Phone:727-551-2033
Practice Address - Fax:278-641-4477
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40854208600000X
ND6639208600000X
FLME119762208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013635800Medicaid
MN67431880Medicaid
MN03T04ABOtherBLUE SHIELD
ND17670Medicaid
NDABD19054OtherBLUE SHIELD
FLHV868ZMedicare PIN
FL013635800Medicaid
MN67431880Medicaid