MEDICARE: DR. SHANNON LEIGH CALVERT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	2004015320	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000000	OTHER	MO	NO NUMBER AVAILABLE

General Provider Information

NPI Number	:	1902919814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON LEIGH CALVERT MD

Provider Business Mailing Address
First Line	:	1500 N OAKLAND AVE
Second Line	:
City	:	BOLIVAR
State	:	MO
Zip	:	65613-3011
Country	:	US
Telephone Number	:	417-328-6501
Fax Number	:	417-328-6338

Provider Business Practice Location Address
First Line	:	1195 N OAKLAND AVE
Second Line	:	SUITE 2
City	:	BOLIVAR
State	:	MO
Zip	:	65613-8095
Country	:	US
Telephone Number	:	417-777-2121
Fax Number	:	417-777-2854

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	02/23/2017

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