NPIMap

Organization Active NPI

Shell Lake Clinic, LTD

  • Family Medicine Physician
  • Shell Lake, WI
National Provider Identifier
1508225988
Registry record updated Feb 15, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
61281-20 Issued in WI
Legal business name
SHELL LAKE CLINIC, LTD
Practice address
105 4TH Ave
Shell Lake, WI 54871-4457
Phone
(715) 468-2711
Fax
(715) 468-2727
NPI assigned
Feb 15, 2016
Last updated
Feb 15, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 15, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jeffrey L. Dunham, M D
Title
President
Phone
(715) 468-2711

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 61281-20 WI Primary

Addresses

Primary practice location

105 4TH Ave
Shell Lake, WI 54871-4457

Mailing address

105 4TH Ave
Shell Lake, WI 54871-4457
Phone (715) 468-2711

Other identifiers 1

IdentifierTypeStateIssuer
1932141157MedicaidWI

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1455494400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1455494400000",
    "number": "1508225988",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "105 4TH AVE",
            "city": "SHELL LAKE",
            "state": "WI",
            "postal_code": "548714457",
            "telephone_number": "715-468-2711",
            "fax_number": "715-468-2727"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "105 4TH AVE",
            "city": "SHELL LAKE",
            "state": "WI",
            "postal_code": "548714457",
            "telephone_number": "715-468-2711",
            "fax_number": "715-468-2727"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHELL LAKE CLINIC, LTD",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-02-15",
        "last_updated": "2016-02-15",
        "status": "A",
        "authorized_official_last_name": "DUNHAM",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "L.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "715-468-2711",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M D"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "61281-20",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1932141157",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Shell Lake, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 15, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.