MEDICARE: SHEA FAMILY MEDICINE

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	207Q00000X	Family Medicine Physician	24988	OK

General Provider Information

NPI Number	:	1578894747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHEA FAMILY MEDICINE

Provider Business Mailing Address
First Line	:	5112 W GORE BLVD STE 1
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73505-5909
Country	:	US
Telephone Number	:	580-699-3900
Fax Number	:	580-699-3901

Provider Business Practice Location Address
First Line	:	5112 W GORE BLVD STE 1
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73505-5909
Country	:	US
Telephone Number	:	580-699-3900
Fax Number	:	580-699-3901

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ELENA S SHEA
Credential	:	M.D.
Telephone Number	:	580-475-0175

Provider Enumeration Date	:	01/27/2010
Last Update Date	:	08/11/2010

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Directions to “SHEA FAMILY MEDICINE ” Practice Location

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