Stag Blair Shadduck

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

TC072 Issued in KY

Practice address

560 S Loop Rd
Edgewood, KY 41017-3405

Phone

(859) 301-2663

Fax

(859) 817-7848

NPI assigned

Jan 27, 2021

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in KY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2021

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Orthocincy Orthopaedics and Sports Medicine PSCGroup PAC ID 3173500196, 163 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• St Elizabeth Florence Hospital, Florence, KY, CCN 180045
• St Elizabeth Edgewood Hospital, Edgewood, KY, CCN 180035

Merit-based Incentive Payment System (MIPS)

Final score

93.01 of 100Reported as apm

Quality

86.02

Promoting interoperability

100

Improvement activities

40

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: sshadduck354586@direct-prd.stelizabeth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Orthocincy Orthopaedics & Sports Medicine PSC

  • Orthopaedic Surgery Physician
  • Edgewood, KY
  • NPI 1598714560

  Multi-Specialty

  Medicare reassignment Care Compare group NPD
• Orthocincy Orthopaedics & Sports Medicine PSC

  • Physical Therapist
  • Montgomery, OH
  • NPI 1003791054

  Multi-Specialty

  NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• St Elizabeth Medical Center, Inc

  • General Acute Care Hospital
  • Florence, KY
  • NPI 1154365062
  Care Compare affiliation
• St Elizabeth Medical Center, Inc

  • General Acute Care Hospital
  • Edgewood, KY
  • NPI 1467492421
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1611705600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1629244800000",
    "number": "1962093674",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "560 S LOOP RD",
            "city": "EDGEWOOD",
            "state": "KY",
            "postal_code": "410173405",
            "telephone_number": "859-301-2663",
            "fax_number": "859-817-7848"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "560 S LOOP RD",
            "city": "EDGEWOOD",
            "state": "KY",
            "postal_code": "410173405",
            "telephone_number": "859-301-2663",
            "fax_number": "859-817-7848"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SHADDUCK",
        "first_name": "STAG",
        "middle_name": "BLAIR",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2021-01-27",
        "last_updated": "2021-08-18",
        "certification_date": "2021-08-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": "KY",
            "license": "TC072",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Alhasan Sedeeq, M.D.
• Katherine Sedlak, PA-C
• Diane Marie Seibert, PT
• Jennifer Lee Merkle Serey, APRN
• Alyssa Sheree Ann Sexton, RBT
• Phalgoon A. Shah, MD
• Pratish H Shah, MD
• Anusha Gopalkrishna Shanbhag
• Samar Sharma, M.D.
• Leslie Sharp, LCSW

• Physician Assistant in Edgewood, KY
• Providers in Edgewood, KY by specialty
• Physician Assistant in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 18, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.