Provider Demographics
NPI:1811933906
Name:YATES, SHANE ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ALLEN
Last Name:YATES
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 1:860 E BROAD ST
Mailing Address - Street 2:SUITE I
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6542
Mailing Address - Country:US
Mailing Address - Phone:440-323-8458
Mailing Address - Fax:440-323-7900
Practice Address - Street 1:630 E RIVER ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5902
Practice Address - Country:US
Practice Address - Phone:440-323-8458
Practice Address - Fax:440-323-7900
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070189207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2191042Medicaid
OHH14859Medicare UPIN
OH2191042Medicaid