MEDICARE: SHANE MICHAEL WILLIAMS 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	207Q00000X	Family Medicine Physician	11405599-1205	UT

General Provider Information

NPI Number	:	1871099309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE MICHAEL WILLIAMS MD

Provider Business Mailing Address
First Line	:	375 S CHIPETA WAY STE A
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1261
Country	:	US
Telephone Number	:	801-581-7914
Fax Number	:

Provider Business Practice Location Address
First Line	:	375 S CHIPETA WAY STE A
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1261
Country	:	US
Telephone Number	:	440-263-8777
Fax Number	:

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

Provider Enumeration Date	:	04/03/2018
Last Update Date	:	09/12/2019

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