Basic Information
Provider Information | |||||||||
NPI: | 1689621336 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHULL | ||||||||
FirstName: | GRETCHEN | ||||||||
MiddleName: | DENISE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 MERCY WAY | ||||||||
Address2: | STE 580 | ||||||||
City: | JOPLIN | ||||||||
State: | MO | ||||||||
PostalCode: | 648044524 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4175568555 | ||||||||
FaxNumber: | 4175568553 | ||||||||
Practice Location | |||||||||
Address1: | 100 MERCY WAY | ||||||||
Address2: | STE 580 | ||||||||
City: | JOPLIN | ||||||||
State: | MO | ||||||||
PostalCode: | 648044524 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4175568555 | ||||||||
FaxNumber: | 4175568553 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/28/2006 | ||||||||
LastUpdateDate: | 03/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 31728 | KS | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RE0101X | 2009008010 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 200377150F | 05 | KS |   | MEDICAID | 200252390A | 05 | OK |   | MEDICAID | P00800435 | 01 | MO | RAIL ROAD MEDICARE | OTHER | 1689621336 | 05 | MO |   | MEDICAID |