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General NPI Number Information
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NPI Number | 1073002630
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Entity Type | Individual
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Provider Name | SHELBY TYRUS ETHRIDGE RT (R) (CT)
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Gender | Male
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Dates
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Enumeration Date | 05/08/2018
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Last Update Date | 05/08/2018
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Provider Practice Location Address
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Address Line | 3200 VINE ST
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City | CINCINNATI
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State | OH
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Zip | 45220-2213
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Country | US
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Telephone | 513-861-3100
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Fax |
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Provider Business Mailing Address
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Address Line | 3355 BAUERWOOD DR
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City | CINCINNATI
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State | OH
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Zip | 45251-2911
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Country | US
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Telephone | 513-207-2111
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | R8859300
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License Number State | OH
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