Provider Demographics
NPI:1801045133
Name:SHIPPERT, BRIAN W (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:W
Last Name:SHIPPERT
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 1:1800 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-6709
Mailing Address - Country:US
Mailing Address - Phone:814-278-4818
Mailing Address - Fax:814-234-6150
Practice Address - Street 1:1800 E PARK AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6709
Practice Address - Country:US
Practice Address - Phone:814-278-4818
Practice Address - Fax:814-234-6150
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014818207LC0200X, 207P00000X
NC2010-00473207P00000X
FLOS11793207P00000X
VA0102203823207P00000X
IL036155857207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGS912ZMedicare PIN
FL007185900Medicaid