Provider Demographics
NPI:1174660112
Name:SHELBY PRIMARY CARE LLC
Entity Type:Organization
Organization Name:SHELBY PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARION
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEMERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-347-2828
Mailing Address - Street 1:24 E WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-1246
Mailing Address - Country:US
Mailing Address - Phone:419-347-2828
Mailing Address - Fax:419-347-2246
Practice Address - Street 1:24 E WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1246
Practice Address - Country:US
Practice Address - Phone:419-347-2828
Practice Address - Fax:419-347-2246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2350030Medicaid
OH2350030Medicaid