1811103468 NPI number — DR. JACK L SHORTRIDGE ED.D.

Table of content: DR. JACK L SHORTRIDGE ED.D. (NPI 1811103468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811103468 NPI number — DR. JACK L SHORTRIDGE ED.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHORTRIDGE
Provider First Name:
JACK
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED.D.
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:
1811103468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 W SHEPARD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMMERVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29483-4242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-821-0323
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 INTERNATIONAL BLVD
Provider Second Line Business Practice Location Address:
WEBSTER UNIVERSITY
Provider Business Practice Location Address City Name:
N CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29418-6937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-760-1324
Provider Business Practice Location Address Fax Number:
843-760-1153
Provider Enumeration Date:
05/14/2007

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: 103TC1900X , with the licence number:  KY-178 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: 1213 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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