| Name: | Shelby Dermatology, P.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Corporation |
| Status: | Exists |
| Date of registration: | 18 Jan 2006 (19 years ago) |
| Entity Number: | 000-245-242 |
| Register Number: | 000245242 |
| ZIP code: | 35007 |
| County: | Shelby |
| Place of Formation: | Shelby County |
| Principal Address: | ALABASTER, AL |
| Registered Office Street Address: | 1022 1ST ST NORTH STE 201ALABASTER, AL 35007 |
| Authorized Capital: | $1,000 |
Activities
MEDICAL PRACTICE/DERMATOLOGY SERVICES
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1740375856 | 2006-10-04 | 2020-08-22 | 1022 1ST STREET NORTH, SUITE 201, ALABASTER, AL, 35007, US | 1022 1ST STREET NORTH, SUITE 201, ALABASTER, AL, 35007, US | |||||||||||||||||||||||
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| Phone | +1 205-621-9500 |
Authorized person
| Name | ROBERT LAND HENDERSON JR. |
| Role | PRESIDENT |
| Phone | 2056219500 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | 00025681 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS |
| Number | 51532549 |
| State | AL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SHELBY DERMATOLOGY, PC 401(K) PLAN | 2017 | 204101634 | 2018-04-30 | SHELBY DERMATOLOGY, P.C. | 14 | |||||||||||||||||||||
|
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| Role | Plan administrator |
| Date | 2018-04-30 |
| Name of individual signing | ROBERT HENDERSON |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2007-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 2056219500 |
| Plan sponsor’s address | 1022 1ST STREET NORTH, SUITE 201, ALABASTER, AL, 35007 |
Signature of
| Role | Plan administrator |
| Date | 2017-05-22 |
| Name of individual signing | ROBERT HENDERSON |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2007-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 2056219500 |
| Plan sponsor’s address | 1022 1ST STREET NORTH, SUITE 201, ALABASTER, AL, 35007 |
Signature of
| Role | Plan administrator |
| Date | 2016-05-19 |
| Name of individual signing | ROBERT HENDERSON |
| Name | Role |
|---|---|
| HENDERSON, ROBERT L JR | Agent |
| Name | Role |
|---|---|
| WARREN, LISA | Incorporator |
Date of last update: 02 Aug 2024
Sources: Alabama Secretary of State
