Basic Information
| Provider Information | |||||||||
| NPI: | 1487639878 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAHADY | ||||||||
| FirstName: | GERTRUDE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 69 | ||||||||
| Address2: | |||||||||
| City: | RUSTBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245880069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343327367 | ||||||||
| FaxNumber: | 4343321757 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 VILLAGE HWY | ||||||||
| Address2: | |||||||||
| City: | RUSTBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245884591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343327367 | ||||||||
| FaxNumber: | 4343321757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101229867 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 005644526 | 05 | VA | MEDICAID | 460635 | 01 | ANTHEM | OTHER | 080186503 | 01 | VA | MEDICARE RAILROAD | OTHER | 0907130004 | 01 | VA | DME RUSTBURG | OTHER | 1487639878 | 05 | VA | MEDICAID |