Provider Demographics
NPI:1588621528
Name:SHAWN MICHAEL ANDERSON MD LLC
Entity Type:Organization
Organization Name:SHAWN MICHAEL ANDERSON MD LLC
Other - Org Name:ANDERSON FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-786-2226
Mailing Address - Street 1:900 E 13TH
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344
Mailing Address - Country:US
Mailing Address - Phone:918-786-2226
Mailing Address - Fax:918-786-8857
Practice Address - Street 1:900 E 13TH
Practice Address - Street 2:SUITE 102
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344
Practice Address - Country:US
Practice Address - Phone:918-786-2226
Practice Address - Fax:918-786-8857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H70170Medicare UPIN