Basic Information
| Provider Information | |||||||||
| NPI: | 1942294764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHADE | ||||||||
| FirstName: | CHARNETTE | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7200 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529370200 | ||||||||
| FaxNumber: | 2524510056 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 ENTERPRISE DR | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278049590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524513100 | ||||||||
| FaxNumber: | 2529373106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 03/08/2019 | ||||||||
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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 | 208000000X | 200400745 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 9568009 | 01 | NC | CIGNA HEALTHCARE | OTHER | D5324 | 01 | NC | MEDCOST | OTHER | 1902525 | 01 | NC | UNITED HEALTH CARE | OTHER | 137AJ | 01 | NC | BCBSNC | OTHER | 89137AJ | 05 | NC | MEDICAID |