1194892125 NPI number — SHELBYVILLE CLINIC CORP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194892125 NPI number — SHELBYVILLE CLINIC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELBYVILLE CLINIC CORP
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:
6
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:
1194892125
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 FRANKLIN RD # 135A-590
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-3280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-465-3152
Provider Business Mailing Address Fax Number:
615-465-3018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
841 UNION ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37160-2610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-685-5522
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUSSEY
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
S
Authorized Official Title or Position:
SR GROUP VP PRESIDENT
Authorized Official Telephone Number:
931-685-5522

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3732391 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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