Basic Information
| Provider Information | |||||||||
| NPI: | 1760532386 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHELBYVILLE CLINIC CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | COMMUNITY HEART CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 FRANKLIN RD # 135A-590 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370273280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778481463 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 841 UNION ST | ||||||||
| Address2: | STE 205 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371602610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9316855535 | ||||||||
| FaxNumber: | 9316855544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 08/07/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUSSEY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9316855535 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHELBYVILLE CLINIC CORP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 3732391 | 05 | TN | MEDICAID |