Basic Information
| Provider Information | |||||||||
| NPI: | 1326195504 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIPLEY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 367 S ANDY GRIFFITH PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270304010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364439190 | ||||||||
| FaxNumber: | 3367455936 | ||||||||
| Practice Location | |||||||||
| Address1: | 367 S ANDY GRIFFITH PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270304010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364439190 | ||||||||
| FaxNumber: | 3367455936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 519 | NC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | 519 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1326195504 | 05 | NC | MEDICAID | NCA058B699 | 01 | NC | MEDICARE PTAN | OTHER | P01459103 | 01 | NC | RAILROAD MEDICARE | OTHER |