Provider Demographics
NPI:1164868667
Name:SHEA, ALICE (MD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629A E HILLSBORO BLVD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-3517
Mailing Address - Country:US
Mailing Address - Phone:954-698-9399
Mailing Address - Fax:954-698-9399
Practice Address - Street 1:964 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:ME
Practice Address - Zip Code:04530-2624
Practice Address - Country:US
Practice Address - Phone:801-888-1406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-11
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD237202085R0202X
CT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1164868667Medicaid