Provider Demographics
NPI:1568818029
Name:SHELBY PEDIATRICS, LLC
Entity Type:Organization
Organization Name:SHELBY PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-726-3980
Mailing Address - Street 1:1431 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-1735
Mailing Address - Country:US
Mailing Address - Phone:937-419-8687
Mailing Address - Fax:937-419-8688
Practice Address - Street 1:1431 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-1735
Practice Address - Country:US
Practice Address - Phone:937-419-8687
Practice Address - Fax:937-419-8688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-13
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075528208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2482586Medicaid