Provider Demographics
NPI:1104929017
Name:SHIPMAN, GROVER GENE (MD)
Entity type:Individual
Prefix:
First Name:GROVER
Middle Name:GENE
Last Name:SHIPMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 12259
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2259
Mailing Address - Country:US
Mailing Address - Phone:888-634-8405
Mailing Address - Fax:
Practice Address - Street 1:914 PINE STREET
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2143
Practice Address - Country:US
Practice Address - Phone:530-926-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25595207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A967380Medicaid
CA00A967380Medicare PIN
CA00A967381Medicare PIN
CAI64168Medicare UPIN