Provider Demographics
NPI:1689944530
Name:BENJAMIN SHETTELL, MD
Entity Type:Organization
Organization Name:BENJAMIN SHETTELL, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-242-1227
Mailing Address - Street 1:2632 EDITH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-3031
Mailing Address - Country:US
Mailing Address - Phone:530-242-1227
Mailing Address - Fax:530-242-6078
Practice Address - Street 1:2632 EDITH AVE STE B
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-3031
Practice Address - Country:US
Practice Address - Phone:530-242-1227
Practice Address - Fax:530-242-6078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106932208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5774539OtherMEDI-CAL PIN NUMBER
DX169AOtherMEDICARE PTAN