Basic Information
| Provider Information | |||||||||
| NPI: | 1083722805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHELL LAKE CLINIC, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 4TH AVE | ||||||||
| Address2: | P O BOX 336 | ||||||||
| City: | SHELL LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548710336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154682711 | ||||||||
| FaxNumber: | 7154682727 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | SHELL LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548710336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154682711 | ||||||||
| FaxNumber: | 7154682727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 10/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | DUNHAM | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7154682711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32751100 | 05 | WI | MEDICAID |