1952686248 NPI number — SHELNUTT OBSTETRICS & GYNECOLOGY

Table of content: JEFFREY SCOTT CLARK LMHC (NPI 1619505914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952686248 NPI number — SHELNUTT OBSTETRICS & GYNECOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELNUTT OBSTETRICS & GYNECOLOGY
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:
1952686248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 OGLETHORPE AVE
Provider Second Line Business Mailing Address:
SUITE 200B
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30606-2179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-227-1164
Provider Business Mailing Address Fax Number:
706-227-1971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 OGLETHORPE AVE
Provider Second Line Business Practice Location Address:
SUITE 200B
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30606-2179
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-227-1164
Provider Business Practice Location Address Fax Number:
706-227-1971
Provider Enumeration Date:
10/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SHELNUTT
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
JUDSON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
706-227-1164

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  046813 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000827197A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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