Healthcare Provider Details

I. General information

NPI: 1396720132
Provider Name (Legal Business Name): EUGENE HERMAN SHIVELY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1698 OLD LEBANON RD SUITE 2A
CAMPBELLSVILLE KY
42718-9662
US

IV. Provider business mailing address

1698 OLD LEBANON RD
CAMPBELLSVILLE KY
42718-9662
US

V. Phone/Fax

Practice location:
  • Phone: 270-465-2821
  • Fax: 270-789-1756
Mailing address:
  • Phone: 270-465-2821
  • Fax: 270-789-1756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number15931
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: