Provider Demographics
NPI:1114013349
Name:PARAGOULD UROLOGY
Entity Type:Organization
Organization Name:PARAGOULD UROLOGY
Other - Org Name:DEWEY R. SHELLEY M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEWEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-236-3308
Mailing Address - Street 1:1000 W KINGSHIGHWAY STE 8
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4197
Mailing Address - Country:US
Mailing Address - Phone:870-236-3308
Mailing Address - Fax:870-236-8530
Practice Address - Street 1:1000 W KINGSHIGHWAY STE 8
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4197
Practice Address - Country:US
Practice Address - Phone:870-236-3308
Practice Address - Fax:870-236-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4246261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5N102Medicare ID - Type Unspecified
ARB92033Medicare UPIN