Basic Information
| Provider Information | |||||||||
| NPI: | 1730141391 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHELLENBERGER | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2940 E. BANNER GATEWAY DRIVE | ||||||||
| Address2: | SUITE #450 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802566444 | ||||||||
| FaxNumber: | 4802564734 | ||||||||
| Practice Location | |||||||||
| Address1: | 2946 E BANNER GATEWAY DR | ||||||||
| Address2: | #450 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802566444 | ||||||||
| FaxNumber: | 4802564734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
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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 | 2086X0206X | 46704 | AZ | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208600000X | 46704 | AZ | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 275021000 | 05 | FL | MEDICAID |