Provider Demographics
NPI:1689381584
Name:BRYAN C SHELBY MDJD LLC
Entity Type:Organization
Organization Name:BRYAN C SHELBY MDJD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:SHELBY
Authorized Official - Suffix:
Authorized Official - Credentials:MDJD
Authorized Official - Phone:203-221-0090
Mailing Address - Street 1:215 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-3210
Mailing Address - Country:US
Mailing Address - Phone:203-221-0090
Mailing Address - Fax:
Practice Address - Street 1:215 MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-3210
Practice Address - Country:US
Practice Address - Phone:203-221-0090
Practice Address - Fax:844-530-1500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty