Provider Demographics
NPI:1104847706
Name:SHELBY PLASTIC SURGERY SKIN CANCER AND LASER SURGERY CENTER P.C.
Entity Type:Organization
Organization Name:SHELBY PLASTIC SURGERY SKIN CANCER AND LASER SURGERY CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:P
Authorized Official - Last Name:COTTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:205-664-4630
Mailing Address - Street 1:1216 1ST ST N
Mailing Address - Street 2:HWY 31
Mailing Address - City:ALABASTER
Mailing Address - State:AL
Mailing Address - Zip Code:35007-8702
Mailing Address - Country:US
Mailing Address - Phone:205-664-4630
Mailing Address - Fax:205-664-4658
Practice Address - Street 1:1216 1ST ST N
Practice Address - Street 2:HWY 31
Practice Address - City:ALABASTER
Practice Address - State:AL
Practice Address - Zip Code:35007-8702
Practice Address - Country:US
Practice Address - Phone:205-664-4630
Practice Address - Fax:205-664-4658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00010998174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty