1205988573 NPI number — MATTHEW SHEPARD

Table of content: MATTHEW SHEPARD (NPI 1205988573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205988573 NPI number — MATTHEW SHEPARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEPARD
Provider First Name:
MATTHEW
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1205988573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 801143
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64180-1143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-331-5583
Provider Business Mailing Address Fax Number:
573-331-5076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 SAINT FRANCIS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63703-5049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-331-5770
Provider Business Practice Location Address Fax Number:
573-331-3974
Provider Enumeration Date:
01/17/2007

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:  113520 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117199 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 332821 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64069206 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 150428001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110210851 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 208841411 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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