Provider Demographics
NPI:1689667578
Name:SHANE, STEVEN (DO)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:SHANE
Suffix:
Gender:M
Credentials:DO
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 417012
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-7012
Mailing Address - Country:US
Mailing Address - Phone:201-487-7227
Mailing Address - Fax:
Practice Address - Street 1:695 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7951
Practice Address - Country:US
Practice Address - Phone:908-851-8346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03653600207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3744205Medicaid
NJ3744205Medicaid
NJ105099Medicare PIN