Basic Information
Provider Information | |||||||||
NPI: | 1811968704 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHELLANS | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2671 OSWELL ST # 312 | ||||||||
Address2: |   | ||||||||
City: | BAKERSFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 933063152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6616343503 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 420 34TH ST | ||||||||
Address2: |   | ||||||||
City: | BAKERSFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 933012237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6613274647 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2006 | ||||||||
LastUpdateDate: | 03/19/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD16165 | OR | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | G66984 | CA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00G669840 | 05 | CA |   | MEDICAID | 930039808 | 01 | OR | RAILROAD MEDICARE | OTHER | 079231 | 05 | OR |   | MEDICAID |