Provider Demographics
NPI:1740375856
Name:SHELBY DERMATOLOGY, PC
Entity type:Organization
Organization Name:SHELBY DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LAND
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:205-621-9500
Mailing Address - Street 1:1022 1ST STREET NORTH
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ALABASTER
Mailing Address - State:AL
Mailing Address - Zip Code:35007
Mailing Address - Country:US
Mailing Address - Phone:205-621-9500
Mailing Address - Fax:
Practice Address - Street 1:1022 1ST STREET NORTH
Practice Address - Street 2:SUITE 201
Practice Address - City:ALABASTER
Practice Address - State:AL
Practice Address - Zip Code:35007
Practice Address - Country:US
Practice Address - Phone:205-621-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00025681174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51532549OtherBCBS
ALI04450Medicare UPIN