Healthcare Provider Details

I. General information

NPI: 1760447015
Provider Name (Legal Business Name): SHEA CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6133 POPLAR PIKE
MEMPHIS TN
38119-4707
US

IV. Provider business mailing address

PO BOX 17987
MEMPHIS TN
38187-0987
US

V. Phone/Fax

Practice location:
  • Phone: 901-761-9720
  • Fax: 901-683-8440
Mailing address:
  • Phone: 901-761-9720
  • Fax: 901-683-8440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0000000050
License Number StateTN

VIII. Authorized Official

Name: MR. JOHN R GROSS
Title or Position: ADMINISTRATOR
Credential:
Phone: 901-761-9720