Provider Demographics
NPI:1194892125
Name:SHELBYVILLE CLINIC CORP
Entity type:Organization
Organization Name:SHELBYVILLE CLINIC CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR GROUP VP PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:HUSSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-685-5522
Mailing Address - Street 1:330 FRANKLIN RD # 135A-590
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-3280
Mailing Address - Country:US
Mailing Address - Phone:615-465-3152
Mailing Address - Fax:615-465-3018
Practice Address - Street 1:841 UNION ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-2610
Practice Address - Country:US
Practice Address - Phone:931-685-5522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHELBYVILLE CLINIC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-28
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3732391Medicaid
TN3732391Medicare PIN