Provider Demographics
NPI:1235327198
Name:BRIAN T. SHEA DO LLC
Entity Type:Organization
Organization Name:BRIAN T. SHEA DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:303-444-3443
Mailing Address - Street 1:PO BOX 2086
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80522-2086
Mailing Address - Country:US
Mailing Address - Phone:303-444-3443
Mailing Address - Fax:
Practice Address - Street 1:1790 30TH ST
Practice Address - Street 2:SUITE 120
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1022
Practice Address - Country:US
Practice Address - Phone:303-447-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36013207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92021328Medicaid
COC496368Medicare PIN