1487633780 NPI number — SHELBY RADIOLOGICAL ASSOCIATES, PA

Table of content: (NPI 1487633780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487633780 NPI number — SHELBY RADIOLOGICAL ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELBY RADIOLOGICAL ASSOCIATES, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487633780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 N LAFAYETTE ST
Provider Second Line Business Mailing Address:
SUITE 01
Provider Business Mailing Address City Name:
SHELBY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28150-4444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-482-3880
Provider Business Mailing Address Fax Number:
704-487-0294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 N LAFAYETTE ST
Provider Second Line Business Practice Location Address:
SUITE 01
Provider Business Practice Location Address City Name:
SHELBY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28150-4444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-482-3880
Provider Business Practice Location Address Fax Number:
704-487-0294
Provider Enumeration Date:
01/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEHMUELLER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
CORPORATE SECRETARY
Authorized Official Telephone Number:
704-482-3880

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  39419 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 020837299 . This is a "US DEPARTMENT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 148760XX . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8902663 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: E16337 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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