1164425740 NPI number — DR. JOHN H SHELSO MD

Table of content: (NPI 1164182259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164425740 NPI number — DR. JOHN H SHELSO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHELSO
Provider First Name:
JOHN
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164425740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-328-6585
Provider Business Mailing Address Fax Number:
605-328-6512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 W 22ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-312-1000
Provider Business Practice Location Address Fax Number:
605-312-1001
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0205X , with the licence number:  36353 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0205X , with the licence number: 3920 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5440119 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 694544897A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q36354 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0082960 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009992005 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02604722-03 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0587857 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05086744 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64081276 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200031050A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200513750A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 209076900 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82736863 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 977465 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 422400000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7614234 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1470945 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 154141001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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