Basic Information
| Provider Information | |||||||||
| NPI: | 1346207487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOOK | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404465890 | ||||||||
| FaxNumber: | 7404465982 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 256013452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048311530 | ||||||||
| FaxNumber: | 3048311527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 06/29/2010 | ||||||||
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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 | 213ES0103X | 00315 | WV | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 36.002904 | OH | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00787217 | 01 | OH | RAILROAD MEDICARE | OTHER | 0227678 | 05 | OH | MEDICAID | 310917085188 | 01 | OH | OH MEDICAID CARESOURCE | OTHER | 0227678 | 01 | OH | OH MEDICAID MOLINA | OTHER | 000000264924 | 01 | OH MEDICAID UNISON | OTHER | 6420018000 | 05 | WV | MEDICAID |