Provider Demographics
NPI:1780661546
Name:ANDERSON, SHELLEY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
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 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-727-4444
Mailing Address - Fax:231-727-4789
Practice Address - Street 1:1915 HOLTON RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1533
Practice Address - Country:US
Practice Address - Phone:231-672-3333
Practice Address - Fax:231-672-6520
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4287683Medicaid
MIG53890Medicare UPIN