Provider Demographics
NPI:1255384020
Name:SHUGOLL, WAYNE MARTIN (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:MARTIN
Last Name:SHUGOLL
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:PO BOX 766351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4915 NORTON HEALTHCARE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2832
Practice Address - Country:US
Practice Address - Phone:502-891-8300
Practice Address - Fax:502-394-6525
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038751207RC0000X
KY27375207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1050461Medicaid
KY000000049358OtherANTHEM
IN100344830Medicaid
KYP00992206OtherRAILROAD MEDICARE
KY64273758Medicaid
IN890680CMedicare ID - Type UnspecifiedINDIANA MEDICARE
KY64273758Medicaid
KY1050461Medicaid
KY2432867000Medicare ID - Type UnspecifiedPASSPORT ADVANTAGE
KYK003440Medicare PIN