1003905878 NPI number — SHENANDOAH VALLEY PODIATRY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003905878 NPI number — SHENANDOAH VALLEY PODIATRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHENANDOAH VALLEY PODIATRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHENANDOAH VALLEY PODIATRY ASSOCIATES, LTD.
Provider Other Organization Name Type Code:
5
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:
1003905878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 SUMMERFIELD CT
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24019-4579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-904-1458
Provider Business Mailing Address Fax Number:
855-495-0994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 SUMMERFIELD CT
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24019-4579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-904-1458
Provider Business Practice Location Address Fax Number:
855-495-0994
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KELLER
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
540-904-1458

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  0103300725 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 480032174 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9304291 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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