Healthcare Provider Details

I. General information

NPI: 1568818029
Provider Name (Legal Business Name): SHELBY PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 N MAIN AVE
SIDNEY OH
45365-1735
US

IV. Provider business mailing address

1431 N MAIN AVE
SIDNEY OH
45365-1735
US

V. Phone/Fax

Practice location:
  • Phone: 937-419-8687
  • Fax: 937-419-8688
Mailing address:
  • Phone: 937-419-8687
  • Fax: 937-419-8688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35075528
License Number StateOH

VIII. Authorized Official

Name: DR. KAREN S SMITH
Title or Position: DOCTOR
Credential: M.D.
Phone: 937-726-3980