MEDICARE: DR. SHAWN JAMES PETTIS 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	207LP2900X	Pain Medicine (Anesthesiology) Physician	19105	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01167	OTHER	NE	BCBSN
2	2001107	OTHER	NE	SHARE ADV-BERGAN SURG
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	6332	OTHER	NE	MIDLANDS CHOICE
6	94522	OTHER	IA	BCBSIA
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	2001106	OTHER	NE	SHARE ADV - CLARKSON W
12	2001164	OTHER	NE	SHARE ADV - ARBOR ST.

General Provider Information

NPI Number	:	1659421543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAWN JAMES PETTIS MD

Provider Business Mailing Address
First Line	:	9911 WESTCHESTER DR
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68114-3800
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9015 ARBOR ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68124-2056
Country	:	US
Telephone Number	:	402-384-2600
Fax Number	:

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	07/09/2007

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