1427021070 NPI number — DR. MICHAEL W SHOTWELL M.D.

Table of content: DR. MICHAEL W SHOTWELL M.D. (NPI 1427021070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427021070 NPI number — DR. MICHAEL W SHOTWELL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOTWELL
Provider First Name:
MICHAEL
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1427021070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19105 N US HIGHWAY 41
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
LUTZ
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33549-4206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-704-6101
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
684 SIXES RD
Provider Second Line Business Practice Location Address:
SUITE 225
Provider Business Practice Location Address City Name:
HOLLY SPRINGS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30115-8721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-704-6101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2006

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: 208600000X , with the licence number:  053168 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: ME127994 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 163054290A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com