Basic Information
| Provider Information | |||||||||
| NPI: | 1275628679 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAJOR AFFILIATES INC. DBA SHELBYVILLE PEDIATRICS | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 30 W RAMPART ST | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173987337 | ||||||||
| FaxNumber: | 3174210372 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 W RAMPART ST | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173987337 | ||||||||
| FaxNumber: | 3174210372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GLIDDEN | ||||||||
| AuthorizedOfficialFirstName: | SHELLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3173987337 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200250240 | 05 | IN | MEDICAID |