Basic Information
| Provider Information | |||||||||
| NPI: | 1083607410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANTZ | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816576 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 BRANDERMILL BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GAMBRILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210541690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107211507 | ||||||||
| FaxNumber: | 4107211510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 11/29/2013 | ||||||||
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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 | 207Q00000X | D0036203 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4668884 | 01 | AETNA PPO | OTHER | 9961 | 01 | KAISER | OTHER | 0002 | 01 | BCBS | OTHER | 2133458 | 01 | MAMSI | OTHER | 278331200 | 05 | MD | MEDICAID | 609636400 | 01 | FEDERAL WORKMANS COMP | OTHER | 2110345 | 01 | AETNA HMO | OTHER | 52030309 | 01 | BCBS | OTHER | 218331200 | 01 | AMERIGROUP | OTHER |