Provider Demographics
NPI:1639166481
Name:RIFKIN, SHELBY D (MD)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:D
Last Name:RIFKIN
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 1128
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1128
Mailing Address - Country:US
Mailing Address - Phone:573-632-4800
Mailing Address - Fax:573-632-5874
Practice Address - Street 1:1432 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2444
Practice Address - Country:US
Practice Address - Phone:573-632-4800
Practice Address - Fax:573-632-5874
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-043437207R00000X, 207RH0000X
IL036043437207RH0003X
WI21520-20207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-043437Medicaid
MO123240003OtherMEDICARE PTAN
ILC45828Medicare UPIN
IL036-043437Medicaid
IL830001477Medicare PIN
ILL37350Medicare PIN
IL110117283Medicare PIN
ILL91894Medicare PIN
ILL91895Medicare PIN