Basic Information
| Provider Information | |||||||||
| NPI: | 1194758938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELTON | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | CONRAD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 MEXICO RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633761666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364425035 | ||||||||
| FaxNumber: | 6364425036 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 MEXICO RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633761666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364425035 | ||||||||
| FaxNumber: | 6364425036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 2006018031 | MO | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 2006018031 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 205456502 | 05 | MO | MEDICAID |