1487639878 NPI number — GERTRUDE K SHAHADY MD

Table of content: GERTRUDE K SHAHADY MD (NPI 1487639878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487639878 NPI number — GERTRUDE K SHAHADY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAHADY
Provider First Name:
GERTRUDE
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1487639878
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 69
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSTBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24588-0069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-332-7367
Provider Business Mailing Address Fax Number:
434-332-1757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
925 VILLAGE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSTBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24588-4591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-332-7367
Provider Business Practice Location Address Fax Number:
434-332-1757
Provider Enumeration Date:
12/08/2005

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: 207Q00000X , with the licence number:  0101229867 , 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: 005644526 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 460635 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 080186503 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0907130004 . This is a "DME RUSTBURG" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1487639878 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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