Provider Demographics
NPI:1932133907
Name:RUCKLE, SHANE (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:RUCKLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 MARKET ST
Mailing Address - Street 2:SUITE 560W
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2614
Mailing Address - Country:US
Mailing Address - Phone:215-662-2286
Mailing Address - Fax:215-615-0500
Practice Address - Street 1:800 SPRUCE ST
Practice Address - Street 2:2 CATHCART
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6130
Practice Address - Country:US
Practice Address - Phone:215-829-3264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067927L207P00000X
NY241661207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001769535Medicaid
NYA400007755Medicare PIN
PA025914Medicare ID - Type Unspecified
NYP00671638Medicare PIN
PAG55329Medicare UPIN
NYA400001189Medicare PIN