Basic Information
| Provider Information | |||||||||
| NPI: | 1497791404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHARECK | ||||||||
| FirstName: | EVERETT | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHARECK | ||||||||
| OtherFirstName: | EVERETT | ||||||||
| OtherMiddleName: | PATRICK | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8117 | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305291306 | ||||||||
| FaxNumber: | 5305294951 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 W SYCAMORE STREET | ||||||||
| Address2: | |||||||||
| City: | WILLOWS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309341800 | ||||||||
| FaxNumber: | 5309341865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 08/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G40509 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G405090 | 05 | CA | MEDICAID |