Provider Demographics
NPI:1366446221
Name:SHELL, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:SHELL
Suffix:
Gender:M
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:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:66839-0289
Mailing Address - Country:US
Mailing Address - Phone:620-364-5395
Mailing Address - Fax:620-364-8719
Practice Address - Street 1:309 SANDERS ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KS
Practice Address - Zip Code:66839-2616
Practice Address - Country:US
Practice Address - Phone:620-364-5395
Practice Address - Fax:620-364-8719
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-23694207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F29363Medicare UPIN
029962Medicare ID - Type Unspecified