Provider Demographics
NPI:1164538567
Name:SHELBURNE, THOMAS M (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:SHELBURNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 S SWAIM STREET EXT
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28642-9418
Mailing Address - Country:US
Mailing Address - Phone:336-835-6300
Mailing Address - Fax:336-835-4761
Practice Address - Street 1:4000 S SWAIM STREET EXT
Practice Address - Street 2:
Practice Address - City:JONESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28642-9418
Practice Address - Country:US
Practice Address - Phone:336-835-6300
Practice Address - Fax:336-835-4761
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8975599Medicaid
NC2485OtherPARTNERS
NC38902OtherMEDCOST
NC4254883OtherAETNA
NC75599OtherBCBSNC
NC080018216Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NCC89484Medicare UPIN
NC4254883OtherAETNA
NC38902OtherMEDCOST