Provider Demographics
NPI:1558415760
Name:SHELBY PEDIATRICS, PSC
Entity Type:Organization
Organization Name:SHELBY PEDIATRICS, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-633-7337
Mailing Address - Street 1:71 MACK WALTERS RD
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1751
Mailing Address - Country:US
Mailing Address - Phone:502-633-7337
Mailing Address - Fax:502-633-7338
Practice Address - Street 1:71 MACK WALTERS RD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1751
Practice Address - Country:US
Practice Address - Phone:502-633-7337
Practice Address - Fax:502-633-7338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1121406163W00000X
KY28387208000000X
KYPA557363AM0700X
KY3006166363LP0200X
KY3007777363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty