Healthcare Provider Details

I. General information

NPI: 1841289659
Provider Name (Legal Business Name): SHANE KEITH ANDERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 05/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 BANNOCK ST
MALAD CITY ID
83252-1256
US

IV. Provider business mailing address

PO BOX 126
MALAD CITY ID
83252-0126
US

V. Phone/Fax

Practice location:
  • Phone: 208-766-2600
  • Fax:
Mailing address:
  • Phone: 208-766-2231
  • Fax: 208-768-4819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2004001424
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11818
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: