Healthcare Provider Details

I. General information

NPI: 1558415760
Provider Name (Legal Business Name): SHELBY PEDIATRICS, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 MACK WALTERS RD
SHELBYVILLE KY
40065-1751
US

IV. Provider business mailing address

71 MACK WALTERS RD
SHELBYVILLE KY
40065-1751
US

V. Phone/Fax

Practice location:
  • Phone: 502-633-7337
  • Fax: 502-633-7338
Mailing address:
  • Phone: 502-633-7337
  • Fax: 502-633-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA557
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number3006166
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1121406
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number3007777
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28387
License Number StateKY

VIII. Authorized Official

Name: ERIC J SIEGEL
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 502-633-7337