1245226935 NPI number — STEPHEN W SHEA D.O.

Table of content: STEPHEN W SHEA D.O. (NPI 1245226935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245226935 NPI number — STEPHEN W SHEA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEA
Provider First Name:
STEPHEN
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1245226935
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
94220 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOLD BEACH
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97444-7756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-247-3000
Provider Business Mailing Address Fax Number:
541-247-3101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97415-9702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-412-2000
Provider Business Practice Location Address Fax Number:
541-412-2081
Provider Enumeration Date:
09/27/2005

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: 207X00000X , with the licence number:  48512-021 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: DO22320 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: R179204 . This is a "MEDICARE FOR RSC" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 14879696985 . This is a "CURRY HEALTH DISTRICT" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 130298 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: R179202 . This is a "MEDICARE FOR CHD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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