Basic Information
| Provider Information | |||||||||
| NPI: | 1093794984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLYNE | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEVESQUE | ||||||||
| OtherFirstName: | SHELLEY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11600 W 2ND PL | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802281527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7203210000 | ||||||||
| FaxNumber: | 7203211759 | ||||||||
| Practice Location | |||||||||
| Address1: | 11600 W 2ND PL | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802281527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7203210000 | ||||||||
| FaxNumber: | 7203211759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 39850 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 39850 | CO | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1093794984 | 01 | CO | NPI # | OTHER | RO103008 | 01 | CO | GROUP ANTHEM BCBS | OTHER | 5334657 | 01 | CO | AETNA | OTHER | 84136530232 | 01 | CO | PACIFICARE | OTHER | 1215981634 | 01 | CO | GROUP NPI # | OTHER | LE654989 | 01 | CO | ANTHEM BCBS | OTHER | 841365302039 | 01 | CT | RKY MTN HMO | OTHER | 04020541 | 05 | CO | MEDICAID | 1836546009 | 01 | CO | CIGNA | OTHER | 70153507 | 05 | CO | MEDICAID | 84136530211 | 01 | CO | PACIFICARE PPO | OTHER | P00381198 | 01 | CO | RAILROAD MEDICARE | OTHER |