1053629964 NPI number — MR. SHAWNLY HEATH WARD SFIDC

Table of content: MR. SHAWNLY HEATH WARD SFIDC (NPI 1053629964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053629964 NPI number — MR. SHAWNLY HEATH WARD SFIDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WARD
Provider First Name:
SHAWNLY
Provider Middle Name:
HEATH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
SFIDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053629964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1424 GUST LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23323-2906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-462-7491
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SURFACE WARFARE MEDICAL INSTITUTE - EAST
Provider Second Line Business Practice Location Address:
459 BELLINGER BLVD
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-322-9298
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)