Provider Demographics
NPI:1043389760
Name:SHELLEY, JAMES MASON JR (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MASON
Last Name:SHELLEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 E PRIMROSE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5178
Mailing Address - Country:US
Mailing Address - Phone:417-269-4646
Mailing Address - Fax:417-269-8078
Practice Address - Street 1:1000 E PRIMROSE ST STE 550
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5180
Practice Address - Country:US
Practice Address - Phone:417-269-4647
Practice Address - Fax:417-269-8078
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO107697207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO159012OtherBLUECROSS BLUESHIELD
MO421539307OtherFED TAX ID
MOF08323Medicare UPIN
MO421539307OtherFED TAX ID
MO007013687Medicare ID - Type UnspecifiedMEDICARE-LAB
MO159012OtherBLUECROSS BLUESHIELD