Basic Information
| Provider Information | |||||||||
| NPI: | 1104816321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHADE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1821 | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437021821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404553342 | ||||||||
| FaxNumber: | 7404553686 | ||||||||
| Practice Location | |||||||||
| Address1: | 945 BETHESDA DR | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437010801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404554530 | ||||||||
| FaxNumber: | 7404544647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 02/19/2010 | ||||||||
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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 | 207R00000X | 35060439 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0815809 | 05 | OH | MEDICAID |