Provider Demographics
NPI:1598725111
Name:ANDERSON, SHAWN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:MICHAEL
Last Name:ANDERSON
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 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-2841
Mailing Address - Country:US
Mailing Address - Phone:918-787-4200
Mailing Address - Fax:918-787-4299
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2841
Practice Address - Country:US
Practice Address - Phone:918-786-2243
Practice Address - Fax:918-787-3643
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22018207P00000X, 207Q00000X
ARE-14312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100114040AMedicaid
OK200264400AMedicaid
MO207446204Medicaid
OK200059690AMedicaid
OK200059690AMedicaid
OK200264400AMedicaid
P00345091Medicare PIN
249535513Medicare PIN
400522511Medicare PIN
H70170Medicare UPIN
OK0A5065Medicare PIN