Provider Demographics
NPI:1982928701
Name:W. EDWARD SHUTTLEWORTH PSC
Entity Type:Organization
Organization Name:W. EDWARD SHUTTLEWORTH PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SHUTTLEWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-338-9653
Mailing Address - Street 1:1008 MEDICAL CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:POWDERLY
Mailing Address - State:KY
Mailing Address - Zip Code:42367-5463
Mailing Address - Country:US
Mailing Address - Phone:270-338-9653
Mailing Address - Fax:270-338-9656
Practice Address - Street 1:1008 MEDICAL CENTER DR STE A
Practice Address - Street 2:
Practice Address - City:POWDERLY
Practice Address - State:KY
Practice Address - Zip Code:42367-5463
Practice Address - Country:US
Practice Address - Phone:270-338-9653
Practice Address - Fax:270-338-9656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64178551Medicaid