Provider Demographics
NPI:1801212154
Name:HARBAUGH, SHANE I
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:HARBAUGH
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CLAY CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47841-1302
Mailing Address - Country:US
Mailing Address - Phone:812-939-2900
Mailing Address - Fax:
Practice Address - Street 1:104 E 8TH ST
Practice Address - Street 2:
Practice Address - City:CLAY CITY
Practice Address - State:IN
Practice Address - Zip Code:47841-1302
Practice Address - Country:US
Practice Address - Phone:812-939-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8906379165172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver