Basic Information
| Provider Information | |||||||||
| NPI: | 1629066626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHACK | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3425 N CARLISLE ST | ||||||||
| Address2: | 2ND FLOOR HUDSON BLDG | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157074739 | ||||||||
| FaxNumber: | 2157073677 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E LEHIGH AVE | ||||||||
| Address2: | MAB BLDG STE 105 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191251000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157078496 | ||||||||
| FaxNumber: | 2157074086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD045140L | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0013992500004 | 05 | PA | MEDICAID |