Basic Information
| Provider Information | |||||||||
| NPI: | 1023069291 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHELBY ANESTHESIOLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 890561 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282890561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009191190 | ||||||||
| FaxNumber: | 7067372272 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 E GROVER ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281503917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044873000 | ||||||||
| FaxNumber: | 7067372272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SURRATT | ||||||||
| AuthorizedOfficialFirstName: | WILSON | ||||||||
| AuthorizedOfficialMiddleName: | FARRIS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7044825716 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 367500000X | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | NC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 7901418 | 05 | NC | MEDICAID | 01418 | 01 | NC | BLUE CROSS | OTHER |