Basic Information
| Provider Information | |||||||||
| NPI: | 1093703175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIRO | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20169 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240180506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407672700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1915 S 17TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284016681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103629511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 07/30/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 30859 | NC | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 75966 | 01 | NC | BCBS OF NC | OTHER | 8975966 | 05 | NC | MEDICAID | 220012149 | 01 | RAILROAD MEDICARE | OTHER | Q30859 | 05 | SC | MEDICAID |