Basic Information
| Provider Information | |||||||||
| NPI: | 1063725273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHARP | ||||||||
| FirstName: | SHASTINE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 BARRET AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402041743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312458600 | ||||||||
| FaxNumber: | 9312458660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2010 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 50146 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MT197438 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 47825 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100650020 | 05 | KY | MEDICAID | 1532928 | 05 | TN | MEDICAID |