1972602886 NPI number — DR. SHAWNA LYN BULL PHELPS MD

Table of content: DEREK HARMANLI MD (NPI 1922856095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972602886 NPI number — DR. SHAWNA LYN BULL PHELPS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHELPS
Provider First Name:
SHAWNA
Provider Middle Name:
LYN BULL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BULL
Provider Other First Name:
SHAWNA
Provider Other Middle Name:
LYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1972602886
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
ATTN: PAYER CONTRACTING & RELATIONS
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28803-2493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-274-7502
Provider Business Practice Location Address Fax Number:
828-271-6599
Provider Enumeration Date:
09/21/2006

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: 207VX0201X , with the licence number:  2013-01236 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207VX0000X , with the licence number: 2013-01236 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 171282001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 171282004 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200215610A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 171282003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00748698 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1972602886 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8AQ004 . This is a "BCBSTX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01267093 . This is a "RAILROAD MCR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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