Basic Information
| Provider Information | |||||||||
| NPI: | 1952424657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | LOREN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVENUE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706244440 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1750 E KEN PRATT BLVD | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805045311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7207187000 | ||||||||
| FaxNumber: | 8702076581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 05/22/2017 | ||||||||
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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 | 58.001782 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | E5527 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | DR0058636 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 173381003 | 05 | AR | MEDICAID | 1952424657 | 05 | MO | MEDICAID | 58.001782 | 01 | OH | OHIO LICENSE TRAINING CER | OTHER | P00924052 | 01 | AR | RAILROAD MEDICARE | OTHER |