1699777524 NPI number — DR. SHANDAL S EMANUEL MD

Table of content: DR. SHANDAL S EMANUEL MD (NPI 1699777524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699777524 NPI number — DR. SHANDAL S EMANUEL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EMANUEL
Provider First Name:
SHANDAL
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
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:
1699777524
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 W NASHVILLE DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27856-1289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-676-8285
Provider Business Mailing Address Fax Number:
252-507-0771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 W NASHVILLE DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27856-1289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-676-8285
Provider Business Practice Location Address Fax Number:
252-507-0771
Provider Enumeration Date:
08/11/2005

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: 207R00000X , with the licence number:  200500405 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 200500405 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 313413 . This is a "WELLPATH ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6114784 . This is a "CIGNA ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5607350 . This is a "FIRST HEALTH ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 14015 . This is a "BC/BS ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7740703 . This is a "AETNA ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: E3288 . This is a "MEDCOST ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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