Provider Demographics
NPI:1760502199
Name:REBECCA S. SHANK MD PA
Entity Type:Organization
Organization Name:REBECCA S. SHANK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:SISK
Authorized Official - Last Name:SHANK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-279-0399
Mailing Address - Street 1:2003 ROCKVIEW DR.
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049
Mailing Address - Country:US
Mailing Address - Phone:817-279-0399
Mailing Address - Fax:817-573-8338
Practice Address - Street 1:2003 ROCKVIEW DR.
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049
Practice Address - Country:US
Practice Address - Phone:817-279-0399
Practice Address - Fax:817-573-8338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH88322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD57898Medicare UPIN
TX00X537Medicare PIN