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
State | License ID | Taxonomies |
---|---|---|
PA | MD067927L | 207P00000X |
NY | 241661 | 207P00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 001769535 | Medicaid | |
NY | A400007755 | Medicare PIN | |
PA | 025914 | Medicare ID - Type Unspecified | |
NY | P00671638 | Medicare PIN | |
PA | G55329 | Medicare UPIN | |
NY | A400001189 | Medicare PIN |