1295938546 NPI number — R. DENNIS SHELBY

Table of content: (NPI 1295938546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295938546 NPI number — R. DENNIS SHELBY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
R. DENNIS SHELBY
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:
1295938546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 N MICHIGAN AVE
Provider Second Line Business Mailing Address:
2413
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60601-7401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-458-9214
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
348 E 1325 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTERTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46304-9540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-458-9214
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHELBY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
DENNIS
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
312-458-9214

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149002949 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01671068 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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