Provider Demographics
NPI:1871536946
Name:SHELBY BAPTIST SPORTS MEDICINE AND FAMILY MEDICINE
Entity type:Organization
Organization Name:SHELBY BAPTIST SPORTS MEDICINE AND FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF INTEGRATION OFFICIER
Authorized Official - Prefix:
Authorized Official - First Name:G.
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-715-5415
Mailing Address - Street 1:PO BOX 830605
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35283-0605
Mailing Address - Country:US
Mailing Address - Phone:205-715-5943
Mailing Address - Fax:205-715-5932
Practice Address - Street 1:831 1ST ST N
Practice Address - Street 2:
Practice Address - City:ALABASTER
Practice Address - State:AL
Practice Address - Zip Code:35007-8944
Practice Address - Country:US
Practice Address - Phone:205-358-9120
Practice Address - Fax:205-358-9121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAPTIST HEALTH CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-14
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5766440001Medicare NSC