Provider Demographics
NPI:1134218258
Name:NORBERG, SHANI KAY (MD)
Entity type:Individual
Prefix:
First Name:SHANI
Middle Name:KAY
Last Name:NORBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MARYLAND FARMS STE 200
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5780
Mailing Address - Country:US
Mailing Address - Phone:800-348-4565
Mailing Address - Fax:
Practice Address - Street 1:200 UNIVERSITY AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2507
Practice Address - Country:US
Practice Address - Phone:651-325-2121
Practice Address - Fax:651-325-2122
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1374792084N0400X, 2084N0402X
NMMD2020-06142084N0400X
MN385562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMMD2020-0614OtherNEW MEXICO MEDICAL BOARD
OH0026453Medicaid
MN223610900Medicaid