Basic Information
| Provider Information | |||||||||
| NPI: | 1710129499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORTER | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | MAYHOOD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAYHOOD | ||||||||
| OtherFirstName: | MEGHAN | ||||||||
| OtherMiddleName: | KRISTINE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4300 MARKETPOINTE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554355435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528359880 | ||||||||
| FaxNumber: | 9528571554 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 MARKETPOINTE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554355435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528359880 | ||||||||
| FaxNumber: | 9528571554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2009 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD2011-0740 | NM | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | A127837 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 70569 | MN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.