Basic Information
| Provider Information | |||||||||
| NPI: | 1588651715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELTON | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | RANDOLPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076812241 | ||||||||
| FaxNumber: | 4076792241 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076812241 | ||||||||
| FaxNumber: | 4076792779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 16669 | WV | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | 45121 | KY | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 2081P2900X | 16669 | WV | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208100000X | 45121 | KY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0113641000 | 05 | WV | MEDICAID | 7100210600 | 05 | KY | MEDICAID |