Basic Information
| Provider Information | |||||||||
| NPI: | 1427013903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAEFFER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 PENNSYLVANIA AVE | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | OTTUMWA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525016413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416825481 | ||||||||
| FaxNumber: | 6416823438 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 PENNSYLVANIA AVE | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | OTTUMWA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525016413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416825481 | ||||||||
| FaxNumber: | 6416823438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 08/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 23165 | IA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1427013903 | 01 | IA | BCBS | OTHER | 0196360 | 05 | IA | MEDICAID |