MEDICARE: MR. KEVIN A SHELBY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	MA052311	PA

General Provider Information

NPI Number	:	1164455838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN A SHELBY PA-C

Provider Business Mailing Address
First Line	:	2630 HOLME AVE
Second Line	:	2ND FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3004
Country	:	US
Telephone Number	:	267-339-3500
Fax Number	:	267-339-3763

Provider Business Practice Location Address
First Line	:	2630 HOLME AVE
Second Line	:	2ND FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3004
Country	:	US
Telephone Number	:	267-339-3500
Fax Number	:	267-339-3763

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	05/13/2009

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