1689944530 NPI number — BENJAMIN SHETTELL, MD

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 1689944530 NPI number — BENJAMIN SHETTELL, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENJAMIN SHETTELL, MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1689944530
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2632 EDITH AVE STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDDING
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96001-3031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-242-1227
Provider Business Mailing Address Fax Number:
530-242-6078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2632 EDITH AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96001-3031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-242-1227
Provider Business Practice Location Address Fax Number:
530-242-6078
Provider Enumeration Date:
01/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
KAYE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
530-242-1227

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  A106932 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5774539 . This is a "MEDI-CAL PIN NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: DX169A . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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