Basic Information
| Provider Information | |||||||||
| NPI: | 1346473287 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NES OF SHELBY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636482 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003778721 | ||||||||
| FaxNumber: | 3046971155 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 MORRIS RD | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448751152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193425015 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2009 | ||||||||
| LastUpdateDate: | 04/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4154354591 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2983615 | 05 | OH | MEDICAID | DP5709 | 01 | RR MEDICARE | OTHER | 000000640740 | 01 | OH | ANTHEM BCBS | OTHER |