1093794984 NPI number — SHELLEY A CLYNE M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093794984 NPI number — SHELLEY A CLYNE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLYNE
Provider First Name:
SHELLEY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEVESQUE
Provider Other First Name:
SHELLEY
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093794984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11600 W 2ND PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80228-1527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-321-0000
Provider Business Mailing Address Fax Number:
720-321-1759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11600 W 2ND PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80228-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-321-0000
Provider Business Practice Location Address Fax Number:
720-321-1759
Provider Enumeration Date:
01/10/2006

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: 207R00000X , with the licence number:  39850 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 39850 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1093794984 . This is a "NPI #" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: RO103008 . This is a "GROUP ANTHEM BCBS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 5334657 . This is a "AETNA" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 84136530232 . This is a "PACIFICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 1215981634 . This is a "GROUP NPI #" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: LE654989 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 841365302039 . This is a "RKY MTN HMO" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 04020541 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1836546009 . This is a "CIGNA" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 70153507 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 84136530211 . This is a "PACIFICARE PPO" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: P00381198 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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