Basic Information
| Provider Information | |||||||||
| NPI: | 1427055433 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANCHER | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4160 S LAKE CT | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625218440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174259665 | ||||||||
| FaxNumber: | 2174259664 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625213810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174642729 | ||||||||
| FaxNumber: | 2174641693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036-094339 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 24559 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | ME93432 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 24559 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | ME93432 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208600000X | 036-094339 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 24559 | SC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | ME93432 | FL | N | Allopathic & Osteopathic Physicians | Surgery | 207LP2900X | 036-094339 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 336055454 | 01 | IL | BCBS | OTHER | 036094339 | 05 | IL | MEDICAID |