Healthcare Provider Details

I. General information

NPI: 1245226935
Provider Name (Legal Business Name): STEPHEN W SHEA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 5TH ST
BROOKINGS OR
97415-9702
US

IV. Provider business mailing address

94220 4TH ST
GOLD BEACH OR
97444-7756
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-2000
  • Fax: 541-412-2081
Mailing address:
  • Phone: 541-247-3000
  • Fax: 541-247-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number48512-021
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberDO22320
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: