1538166988 NPI number — K DONALD SHELBOURNE MD LLC

Table of content: (NPI 1538166988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538166988 NPI number — K DONALD SHELBOURNE MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
K DONALD SHELBOURNE MD LLC
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:
SHELBOURNE KNEE CENTER AT METHODIST HOSPITAL
Provider Other Organization Name Type Code:
3
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:
1538166988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 N CAPITOL AVE
Provider Second Line Business Mailing Address:
STE 530
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46202-1288
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-924-8636
Provider Business Mailing Address Fax Number:
317-921-0230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1815 N CAPITOL AVE
Provider Second Line Business Practice Location Address:
STE 600
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-1288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-924-8636
Provider Business Practice Location Address Fax Number:
317-921-0230
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SHELBOURNE
Authorized Official First Name:
K
Authorized Official Middle Name:
DONALD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-924-8636

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  01027165A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DB9030 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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