1588090724 NPI number — MARY SUSAN GEGOREK SHUGHRUE RPH, BCACP, CDE

Table of content: MARY SUSAN GEGOREK SHUGHRUE RPH, BCACP, CDE (NPI 1588090724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588090724 NPI number — MARY SUSAN GEGOREK SHUGHRUE RPH, BCACP, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUGHRUE
Provider First Name:
MARY SUSAN
Provider Middle Name:
GEGOREK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPH, BCACP, CDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHUGHRUE
Provider Other First Name:
MARY SUSAN
Provider Other Middle Name:
GEGOREK
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPH, BCACP, CDE
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1588090724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
743 WINCHESTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGAME
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94010-2738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-393-4844
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 PASTEUR DR
Provider Second Line Business Practice Location Address:
M/C 5616
Provider Business Practice Location Address City Name:
STANFORD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94305-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-723-0140
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2013

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: 183500000X , with the licence number:  672221 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: RP041121R , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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