Basic Information
Provider Information | |||||||||
NPI: | 1346245909 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHANLEY | ||||||||
FirstName: | MARGARET | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2060 N PEARL ST | ||||||||
Address2: |   | ||||||||
City: | NORTH EAST | ||||||||
State: | PA | ||||||||
PostalCode: | 164281926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8148777711 | ||||||||
FaxNumber: | 8148777715 | ||||||||
Practice Location | |||||||||
Address1: | 2060 N PEARL ST | ||||||||
Address2: |   | ||||||||
City: | NORTH EAST | ||||||||
State: | PA | ||||||||
PostalCode: | 164281926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8148777711 | ||||||||
FaxNumber: | 8148777715 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2005 | ||||||||
LastUpdateDate: | 11/19/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD060708L | PA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0016602110002 | 05 | PA |   | MEDICAID | 01827196 | 01 | NY | NY MEDICAL ASSISTANCE | OTHER | 080106402 | 01 | PA | RR MEDICARE | OTHER | 967503 | 01 | PA | BLUE SHIELD | OTHER | 212674 | 01 |   | UPMC | OTHER | 00025197801 | 01 | NY | UNIVERA | OTHER | 0949874 | 01 | PA | AETNA | OTHER | 217694 | 01 | PA | UNISON | OTHER | 2227174 | 01 | OH | OH MEDICAL ASSISTANCE | OTHER | P000143 | 01 | PA | GATEWAY | OTHER |