Basic Information
| Provider Information | |||||||||
| NPI: | 1104095033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STINER | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | R | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1317528480 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 747 E. COUNTY LINE ROAD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178889669 | ||||||||
| FaxNumber: | 3178857966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2008 | ||||||||
| LastUpdateDate: | 03/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02003408A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200910100 | 05 | IN | MEDICAID | 000000585951 | 01 | IN | ANTHEM PIN | OTHER |