Provider Demographics
NPI:1548266158
Name:PERTUNEN, SHAWN M (DO)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:M
Last Name:PERTUNEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-9383
Mailing Address - Country:US
Mailing Address - Phone:231-536-2206
Mailing Address - Fax:231-536-7150
Practice Address - Street 1:601 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-9383
Practice Address - Country:US
Practice Address - Phone:231-536-2206
Practice Address - Fax:231-536-7150
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011133207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4312267OtherMOLINA
MISP011133OtherBLUE CROSS BILLING NUMBER
MI4312267Medicaid
MIF59289Medicare UPIN