Provider Demographics
NPI:1790785582
Name:SHAW, MARIANNE L (MD)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:L
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-317-5188
Mailing Address - Fax:814-317-5283
Practice Address - Street 1:1792 PLANK RD
Practice Address - Street 2:
Practice Address - City:DUNCANSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16635-8378
Practice Address - Country:US
Practice Address - Phone:814-317-5188
Practice Address - Fax:814-317-5283
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD4238723207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007706880003Medicaid
PA338517OtherBLUE SHIELD
PA1007706880003Medicaid
035542Medicare ID - Type Unspecified