Provider Demographics
NPI:1760447015
Name:SHEA CLINIC
Entity Type:Organization
Organization Name:SHEA CLINIC
Other - Org Name:SHEA CLINIC, ASC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-761-9720
Mailing Address - Street 1:PO BOX 17987
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-0987
Mailing Address - Country:US
Mailing Address - Phone:901-761-9720
Mailing Address - Fax:901-683-8440
Practice Address - Street 1:6133 POPLAR PIKE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4707
Practice Address - Country:US
Practice Address - Phone:901-761-9720
Practice Address - Fax:901-683-8440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000050261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN490000678OtherRAILROAD MEDICARE
TN3287130Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER