Provider Demographics
NPI:1013929876
Name:WHALEN, SHADE R (MD)
Entity Type:Individual
Prefix:
First Name:SHADE
Middle Name:R
Last Name:WHALEN
Suffix:
Gender:M
Credentials:MD
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Other - Middle Name:
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Mailing Address - Street 1:2115 N KANSAS
Mailing Address - Street 2:CHILDREN & ADOLESCENT CLINIC PC
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901
Mailing Address - Country:US
Mailing Address - Phone:402-463-6828
Mailing Address - Fax:402-463-4767
Practice Address - Street 1:2115 N KANSAS
Practice Address - Street 2:CHILDREN & ADOLESCENT CLINIC PC
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901
Practice Address - Country:US
Practice Address - Phone:402-463-6828
Practice Address - Fax:402-463-4767
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2012-01-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NE23753208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47063717813Medicaid
NE096404Medicare ID - Type Unspecified