Provider Demographics
NPI:1790812188
Name:SHANE, KENNETH ALLAN (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALLAN
Last Name:SHANE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3381 MONTROSE AVENUE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-2411
Mailing Address - Country:US
Mailing Address - Phone:330-666-6801
Mailing Address - Fax:330-666-6801
Practice Address - Street 1:3381 MONTROSE AVENUE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44333-2411
Practice Address - Country:US
Practice Address - Phone:330-666-6801
Practice Address - Fax:330-666-6801
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2011-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002062213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0561682Medicaid
GA480003668OtherRAILROAD MEDICARE
OH000000132340OtherANTHEM BLUE CROSS BLUE SH
TX0007763250OtherAETNA
341466072OtherUNITED AMERICAN INSURANCE
SH0520022OtherSTANDARD LIFE AND ACCIDEN
KY000000165933OtherANTHEM BLUE CROSS BLUE SHIELD
TX0007763250OtherAETNA
341466072OtherUNITED AMERICAN INSURANCE