Provider Demographics
NPI:1083722805
Name:SHELL LAKE CLINIC, LTD
Entity Type:Organization
Organization Name:SHELL LAKE CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DUNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-468-2711
Mailing Address - Street 1:105 4TH AVE
Mailing Address - Street 2:P O BOX 336
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-0336
Mailing Address - Country:US
Mailing Address - Phone:715-468-2711
Mailing Address - Fax:715-468-2727
Practice Address - Street 1:105 4TH AVE
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-0336
Practice Address - Country:US
Practice Address - Phone:715-468-2711
Practice Address - Fax:715-468-2727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32751100Medicaid
WI66020Medicare ID - Type UnspecifiedMEDICARE
WI32751100Medicaid