1598730939 NPI number — DR. GRADY C SHAW MD

Table of content: DR. GRADY C SHAW MD (NPI 1598730939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598730939 NPI number — DR. GRADY C SHAW MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
GRADY
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1598730939
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
219 W 6TH AVE
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
CORSICANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75110-5243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-555-0000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
CORSICANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75110-2415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-872-3005
Provider Business Practice Location Address Fax Number:
903-875-7229
Provider Enumeration Date:
02/21/2006

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: 207P00000X , with the licence number:  F7158 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: F7158 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 125737006 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: DG9311 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00463100 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00Y226 . This is a "MEDICARE GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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