Basic Information
| Provider Information | |||||||||
| NPI: | 1073709143 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 242278 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361242278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343962110 | ||||||||
| FaxNumber: | 3343964905 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 COBB PKWY NW | ||||||||
| Address2: | SUITE 703 | ||||||||
| City: | ACWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301019532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709170924 | ||||||||
| FaxNumber: | 7709170926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH009094 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.