Provider Demographics
NPI:1912082249
Name:MCSHAN, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MCSHAN
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 731218
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-1218
Mailing Address - Country:US
Mailing Address - Phone:903-315-3800
Mailing Address - Fax:903-984-5367
Practice Address - Street 1:1711 S HENDERSON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3563
Practice Address - Country:US
Practice Address - Phone:903-315-3800
Practice Address - Fax:903-984-5367
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4519207P00000X, 207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752883733OtherTAX ID
TX00BP62OtherBLUE CROSS BLUE SHIELD
TX130926203Medicaid
TX00BP62OtherBLUE CROSS BLUE SHIELD
TX00BP62Medicare PIN