1003906793 NPI number — GREGORY B SHASBY PHD, PT

Table of content: GREGORY B SHASBY PHD, PT (NPI 1003906793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003906793 NPI number — GREGORY B SHASBY PHD, PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHASBY
Provider First Name:
GREGORY
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD, PT
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:
1003906793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
771 PILOT HOUSE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23606-1990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-873-2302
Provider Business Mailing Address Fax Number:
757-873-2306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10128 W BROAD ST
Provider Second Line Business Practice Location Address:
FORUM BLDG III, SUITE K
Provider Business Practice Location Address City Name:
GLEN ALLEN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23060-6761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-217-9210
Provider Business Practice Location Address Fax Number:
804-217-9213
Provider Enumeration Date:
10/13/2006

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: 208100000X , with the licence number:  004092 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 2305205897 , 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: 342327 . This is a "BCBS (PHYSICAL THERAPY)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00217523 . This is a "TRAVELERS MEDICARE ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P00930518 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7263602 . This is a "AETNA PROVIDER ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000331732 . This is a "ANTHEM BCBS PROVIDER ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1003906793 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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