Basic Information
| Provider Information | |||||||||
| NPI: | 1679239727 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHIVERS MEDICAL SERVICES LIMITED | ||||||||
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| OtherOrganizationName: | R. MARK SHIVERS SOLE MBR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4347 PORTAGE ST NW | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447207371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306148411 | ||||||||
| FaxNumber: | 3302448521 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 WOODSIDE DRIVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444607688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306148411 | ||||||||
| FaxNumber: | 3302448521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2021 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | SHIVERS | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | MARK | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / MD | ||||||||
| AuthorizedOfficialTelephone: | 3306148411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0975995 | 05 | OH | MEDICAID |