1134163090 NPI number — JOHN G SHEAREN M.D.

Table of content: JOHN G SHEAREN M.D. (NPI 1134163090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134163090 NPI number — JOHN G SHEAREN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEAREN
Provider First Name:
JOHN
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1134163090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2651 HILLCREST DRIVE
Provider Second Line Business Mailing Address:
SUITE 303
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54016-4439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-531-6800
Provider Business Mailing Address Fax Number:
715-531-6801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1997 SLOAN PL
Provider Second Line Business Practice Location Address:
SUITE 17
Provider Business Practice Location Address City Name:
MAPLEWOOD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55117-2094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-531-6800
Provider Business Practice Location Address Fax Number:
715-531-6801
Provider Enumeration Date:
06/15/2006

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: 208600000X , with the licence number:  25906 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 768302200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 32189500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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