Provider Demographics
NPI:1720056369
Name:SHELBYVILLE HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:SHELBYVILLE HOSPITAL CORPORATION
Other - Org Name:WARTRACE FAMILY PRACTICE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP, GROUP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-373-9600
Mailing Address - Street 1:PO BOX 403621
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:507 BLACKMAN BLVD W
Practice Address - Street 2:
Practice Address - City:WARTRACE
Practice Address - State:TN
Practice Address - Zip Code:37183-2210
Practice Address - Country:US
Practice Address - Phone:931-389-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHELBYVILLE HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-09
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000002261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN443439Medicare Oscar/Certification