Basic Information
| Provider Information | |||||||||
| NPI: | 1508811654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDO | ||||||||
| FirstName: | SHANELI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 REGENCY CT | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436233092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194710493 | ||||||||
| FaxNumber: | 4194740390 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 REGENCY CT | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436233092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194710493 | ||||||||
| FaxNumber: | 4194740390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 08/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 239860 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | SF078490 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 69611-20 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 091524 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1508811654 | 05 | MI | MEDICAID | 2837005 | 05 | OH | MEDICAID | P00630915 | 01 | OH | RR MEDICARE | OTHER | P00630915 | 01 | MI | RR MEDICARE | OTHER | 0N24000018 | 01 | MI | MI MEDICARE | OTHER | 1508811654 | 01 | MI | MI MEDICAID - OH LOCATIONS | OTHER |