Provider Demographics
NPI:1689621336
Name:SHULL, GRETCHEN DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:GRETCHEN
Middle Name:DENISE
Last Name:SHULL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:100 MERCY WAY
Mailing Address - Street 2:STE 580
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4524
Mailing Address - Country:US
Mailing Address - Phone:417-556-8555
Mailing Address - Fax:417-556-8553
Practice Address - Street 1:100 MERCY WAY
Practice Address - Street 2:STE 580
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4524
Practice Address - Country:US
Practice Address - Phone:417-556-8555
Practice Address - Fax:417-556-8553
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS31728207R00000X
MO2009008010207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200377150FMedicaid
OK200252390AMedicaid
MOP00800435OtherRAIL ROAD MEDICARE
MO1689621336Medicaid
MOMA2082039Medicare PIN