Provider Demographics
NPI:1225762917
Name:SHEA ORTHOPEDIC AND SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:SHEA ORTHOPEDIC AND SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-984-4500
Mailing Address - Street 1:1580 CREEKSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630
Mailing Address - Country:US
Mailing Address - Phone:916-984-4500
Mailing Address - Fax:915-984-4502
Practice Address - Street 1:1580 CREEKSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630
Practice Address - Country:US
Practice Address - Phone:916-984-4500
Practice Address - Fax:915-984-4502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-11
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty