1861406019 NPI number — ROGER SHEA ,M.D. ,INC.

Table of content: (NPI 1861406019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861406019 NPI number — ROGER SHEA ,M.D. ,INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROGER SHEA ,M.D. ,INC.
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:
ROGER SHEA, M.D., INC.
Provider Other Organization Name Type Code:
3
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:
1861406019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5432 BEE RIDGE RD
Provider Second Line Business Mailing Address:
STE #140
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34233-1514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-371-2244
Provider Business Mailing Address Fax Number:
941-371-1144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5432 BEE RIDGE RD
Provider Second Line Business Practice Location Address:
STE #140
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34233-1514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-371-2244
Provider Business Practice Location Address Fax Number:
941-371-1144
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHEA
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
941-371-2244

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME0065243 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 379122000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103595700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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