Provider Demographics
NPI:1184697484
Name:BACKUS, SHANE KEITH (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:KEITH
Last Name:BACKUS
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 1:13333 NORTHWEST FWY
Mailing Address - Street 2:STE 540
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-6166
Mailing Address - Country:US
Mailing Address - Phone:740-452-9319
Mailing Address - Fax:740-452-2427
Practice Address - Street 1:838 MARKET STREET
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701
Practice Address - Country:US
Practice Address - Phone:740-452-9319
Practice Address - Fax:740-452-2427
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350827242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2409870Medicaid
OHBA4108321Medicare ID - Type Unspecified
H85643Medicare UPIN