Provider Demographics
NPI:1073002630
Name:ETHRIDGE, SHELBY TYRUS (RT (R) (CT))
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:TYRUS
Last Name:ETHRIDGE
Suffix:
Gender:M
Credentials:RT (R) (CT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 BAUERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45251-2911
Mailing Address - Country:US
Mailing Address - Phone:513-207-2111
Mailing Address - Fax:
Practice Address - Street 1:3200 VINE ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2213
Practice Address - Country:US
Practice Address - Phone:513-861-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHR88593002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology