Basic Information
| Provider Information | |||||||||
| NPI: | 1497736441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDES | ||||||||
| FirstName: | KARL | ||||||||
| MiddleName: | SHANE | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1661 HOLLAND RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198437800 | ||||||||
| FaxNumber: | 4198433444 | ||||||||
| Practice Location | |||||||||
| Address1: | 1661 HOLLAND RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198437800 | ||||||||
| FaxNumber: | 4198433444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 35072158F | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | 35072158 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 35072158F | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 2032286 | 05 | OH | MEDICAID | 81000658 | 01 | OH | MEDICARE RAILROAD | OTHER |