1063857779 NPI number — JASON SHELLNUT, MD, PC

Table of content: (NPI 1063857779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063857779 NPI number — JASON SHELLNUT, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JASON SHELLNUT, MD, PC
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:
1063857779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1121 CROOKS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROYAL OAK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48067-1301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-541-8554
Provider Business Mailing Address Fax Number:
248-541-1791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1121 CROOKS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48067-1301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-541-8554
Provider Business Practice Location Address Fax Number:
248-541-1791
Provider Enumeration Date:
05/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LEMAN
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
ASST OFFICE MANAGER
Authorized Official Telephone Number:
248-541-8554

Provider Taxonomy Codes

  • Taxonomy code: 208C00000X , with the licence number:  4301092631 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com