Basic Information
| Provider Information | |||||||||
| NPI: | 1982644175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | BLAIR | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 REID PARKWAY | ||||||||
| Address2: | MEDICAL STAFF SERIVCES | ||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473741157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659358802 | ||||||||
| FaxNumber: | 7659833219 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 N J ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473741913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659833298 | ||||||||
| FaxNumber: | 7659837970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 9901029 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 01083410A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1982644175 | 01 | NC | UNITED HEATLCARE | OTHER | 1982644175 | 01 | NC | AETNA | OTHER | 188031 | 01 | NC | MEDCOST | OTHER | BS4057370 | 01 | NC | DEA CERTIFICATION ID # | OTHER | 1982644175 | 01 | NC | CIGNA | OTHER | 1982644175 | 01 | NC | TRICARE | OTHER | 891218F | 05 | NC | MEDICAID | 1218F | 01 | NC | BCBS PROVIDER ID # | OTHER |