Basic Information
| Provider Information | |||||||||
| NPI: | 1083664874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHENKMAN | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | TYLER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., J.D., LLM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 2ND AVE S | ||||||||
| Address2: | #474 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273180160 | ||||||||
| FaxNumber: | 7272664928 | ||||||||
| Practice Location | |||||||||
| Address1: | 8142 BELLARUS WAY STE 104 | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | TRINITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346551799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278207701 | ||||||||
| FaxNumber: | 7278207700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036000 | GA | N | Other Service Providers | Specialist | 2084N0400X | ME118247 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 36000 | GA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 208M00000X | ME118247 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 000516942H | 05 | GA | MEDICAID | 011898500 | 05 | FL | MEDICAID | P00187661 | 01 | GA | RAILROAD MEDICARE PIN | OTHER |