Provider Demographics
NPI:1174587885
Name:SHAK, BRIAN C (MSPT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:C
Last Name:SHAK
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CHASE HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:PA
Mailing Address - Zip Code:18064-8104
Mailing Address - Country:US
Mailing Address - Phone:610-746-9432
Mailing Address - Fax:
Practice Address - Street 1:318 TOWN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18040-8366
Practice Address - Country:US
Practice Address - Phone:610-253-3300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013574L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7692221OtherAETNA PROVIDER ID
PAP2607186OtherOXFORD PROVIDER ID
PAP00028339OtherRR MEDICARE PROVIDER ID
PA01133301OtherCAPITAL BLUE CROSS PROVID
PA1300887OtherBLUE SHILED PROVIDER ID
PA1300887OtherBLUE SHILED PROVIDER ID