Provider Demographics
NPI:1598878571
Name:SHELBY STEPHENSON
Entity Type:Organization
Organization Name:SHELBY STEPHENSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:A
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-483-3534
Mailing Address - Street 1:414 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3416
Mailing Address - Country:US
Mailing Address - Phone:910-483-3534
Mailing Address - Fax:910-483-0968
Practice Address - Street 1:414 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3416
Practice Address - Country:US
Practice Address - Phone:910-483-3534
Practice Address - Fax:910-483-0968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8979732Medicaid
NC8979732Medicaid
NC=========OtherUNITED HEALTHCARE
NC=========OtherUNITED HEALTHCARE
NC8979732Medicaid