Provider Demographics
NPI:1982623583
Name:SHAW, CHARLES H (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
Last Name:SHAW
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 1:4457 POSSUM RUN ROAD
Mailing Address - Street 2:
Mailing Address - City:BELLVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:370 CLINE AVENUE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907
Practice Address - Country:US
Practice Address - Phone:419-756-8511
Practice Address - Fax:419-756-8513
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-5931174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0563840Medicaid
OH000000025568OtherANTHEM
OH000000025568OtherANTHEM