Basic Information
Provider Information | |||||||||
NPI: | 1891763314 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEPERD | ||||||||
FirstName: | JAIME | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SHEPERD | ||||||||
OtherFirstName: | JIM | ||||||||
OtherMiddleName: | MANUEL | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5010 | ||||||||
Address2: |   | ||||||||
City: | MINOT | ||||||||
State: | ND | ||||||||
PostalCode: | 587025010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7018575650 | ||||||||
FaxNumber: | 7018575031 | ||||||||
Practice Location | |||||||||
Address1: | #1 BURDICK EXPY. W. | ||||||||
Address2: |   | ||||||||
City: | MINOT | ||||||||
State: | ND | ||||||||
PostalCode: | 587014406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7018575220 | ||||||||
FaxNumber: | 7018575245 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/10/2006 | ||||||||
LastUpdateDate: | 01/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD00042373 | WA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | P00765641 | 01 | WA | RAILROAD MEDICARE | OTHER | P00206069 | 01 |   | RAILROAD MEDICARE | OTHER | 1112SH | 01 |   | REGENCE BLUE SHIELD RIDER | OTHER | 8365926 | 05 | WA |   | MEDICAID |