Basic Information
| Provider Information | |||||||||
| NPI: | 1710094420 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHELBY ANESTHESIA SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 172104 | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381872104 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6005 PARK AVE | ||||||||
| Address2: | SUITE 905 B | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381195202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016826828 | ||||||||
| FaxNumber: | 9016829316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 11/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | VICKERS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9016826828 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.