Provider Demographics
NPI:1063857779
Name:JASON SHELLNUT, MD, PC
Entity Type:Organization
Organization Name:JASON SHELLNUT, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-541-8554
Mailing Address - Street 1:1121 CROOKS RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1301
Mailing Address - Country:US
Mailing Address - Phone:248-541-8554
Mailing Address - Fax:248-541-1791
Practice Address - Street 1:1121 CROOKS RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1301
Practice Address - Country:US
Practice Address - Phone:248-541-8554
Practice Address - Fax:248-541-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092631208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty