Provider Demographics
NPI:1962418301
Name:CHRISTOPHER SHELBY M D A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:CHRISTOPHER SHELBY M D A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SEBASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-872-0747
Mailing Address - Street 1:PO BOX 958
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052-0958
Mailing Address - Country:US
Mailing Address - Phone:318-872-0747
Mailing Address - Fax:
Practice Address - Street 1:126 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2602
Practice Address - Country:US
Practice Address - Phone:318-872-0747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA152W00000X
LA025412207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5820530001Medicare NSC
H87909Medicare UPIN