Basic Information
| Provider Information | |||||||||
| NPI: | 1770587172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORTER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | 200 POCAHONTAS TRAIL | ||||||||
| City: | WHITE SULPHUR SPRINGS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249860457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045365030 | ||||||||
| FaxNumber: | 3045365051 | ||||||||
| Practice Location | |||||||||
| Address1: | 756 ATHENS RD | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247406261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044250716 | ||||||||
| FaxNumber: | 3044871322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 01/20/2016 | ||||||||
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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 | 207Q00000X | 1105 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5181179 | 01 | CCN | OTHER | 010109892 | 05 | VA | MEDICAID | 262907 | 01 | CARELINK | OTHER | 3810001390 | 05 | WV | MEDICAID | 1038179 | 01 | WV WORKERS COMPENSATION | OTHER | 4324131 | 01 | AETNA | OTHER | 541839718 | 01 | C&O | OTHER | P00173397 | 01 | WV | RAILROAD MEDICARE | OTHER | 541839718107 | 01 | WV | BS MOUNTAIN STATE | OTHER |