Provider Demographics
NPI:1548257223
Name:SHEA CENTER FOR EARS, HEARING AND BALANCE INC.
Entity type:Organization
Organization Name:SHEA CENTER FOR EARS, HEARING AND BALANCE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:901-382-1200
Mailing Address - Street 1:PO BOX 2153 DEPT 1850
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-0002
Mailing Address - Country:US
Mailing Address - Phone:901-382-1200
Mailing Address - Fax:901-382-8070
Practice Address - Street 1:3265 W SARAZENS CIR
Practice Address - Street 2:SUITE 102
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-0806
Practice Address - Country:US
Practice Address - Phone:901-382-1200
Practice Address - Fax:901-382-8070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000016228174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B58893Medicare UPIN
TN3014433Medicare ID - Type Unspecified