Provider Demographics
NPI:1770556573
Name:SHAWNEE MEDICAL GROUP, P.C.
Entity type:Organization
Organization Name:SHAWNEE MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANITA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SATTERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-421-4759
Mailing Address - Street 1:PO BOX 244
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE ON DELAWARE
Mailing Address - State:PA
Mailing Address - Zip Code:18356-0244
Mailing Address - Country:US
Mailing Address - Phone:570-421-3900
Mailing Address - Fax:570-424-1549
Practice Address - Street 1:BUTTERMILK FALLS ROAD
Practice Address - Street 2:
Practice Address - City:SHAWNEE-ON-DELAWARE
Practice Address - State:PA
Practice Address - Zip Code:18356-0244
Practice Address - Country:US
Practice Address - Phone:570-421-3900
Practice Address - Fax:570-424-1549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031607E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA002113OtherFIRST PRIORITY
PA1007575050001Medicaid
PA414-E105OtherGEISINGER
PA744447OtherBLUE SHIELD
PA1007575050003Medicaid
PA73398OtherUNISON
PA5501209OtherGHI
PA1007575050004Medicaid
PA454980OtherAETNA PPO
PA1007575050003Medicaid
PA744447OtherBLUE SHIELD