Individual
DR. SHANE KEITH ANDERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
220 BANNOCK ST, MALAD CITY, ID 83252-1256
(208) 766-2600
Mailing address
PO BOX 126, MALAD CITY, ID 83252-0126
(208) 766-2231
(208) 768-4819
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
11818
MT
207R00000X
Internal Medicine Physician
2004001424
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000092769
PROVIDER NUMBER
MO
Enumeration date
10/14/2005
Last updated
05/24/2011
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