Provider Demographics
NPI:1801995469
Name:SHELBY COUNTY FAMILY MEDICINE
Entity type:Organization
Organization Name:SHELBY COUNTY FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-392-3211
Mailing Address - Street 1:30 WEST RAMPART STREET
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-8897
Mailing Address - Country:US
Mailing Address - Phone:317-398-0121
Mailing Address - Fax:317-421-2016
Practice Address - Street 1:30 W RAMPART ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8897
Practice Address - Country:US
Practice Address - Phone:317-398-0121
Practice Address - Fax:317-421-2016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100224650AMedicaid
IN741720OtherMEDICARE ID
IN0175050001Medicare NSC