Healthcare Provider Details

I. General information

NPI: 1134109135
Provider Name (Legal Business Name): WILLIAM EDWARD SHUTTLEWORTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 MEDICAL CENTER DR
POWDERLY KY
42367-5463
US

IV. Provider business mailing address

1008 MEDICAL CENTER DR STE A
POWDERLY KY
42367-5463
US

V. Phone/Fax

Practice location:
  • Phone: 270-338-9653
  • Fax: 270-338-1756
Mailing address:
  • Phone: 270-338-9653
  • Fax: 270-338-1756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number17855
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: