Basic Information
| Provider Information | |||||||||
| NPI: | 1083695159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANK | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280013403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049833508 | ||||||||
| FaxNumber: | 7049833509 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280013403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049833508 | ||||||||
| FaxNumber: | 7049833509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 02/04/2008 | ||||||||
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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 | 207Q00000X | 109181 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 89132T2 | 05 | NC | MEDICAID |