Provider Demographics
NPI:1811959927
Name:SHANE, SUSAN P (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:SHANE
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:PO BOX 1150
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05402-1150
Mailing Address - Country:US
Mailing Address - Phone:802-847-8161
Mailing Address - Fax:
Practice Address - Street 1:1 SOUTH PROSPECT STREET
Practice Address - Street 2:FAHC FAMILY MEDICINE, ARNOLD 4
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-847-4237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0007826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009335Medicaid
VTE62281Medicare UPIN
VTVT9335Medicare ID - Type Unspecified