Provider Demographics
NPI:1003905878
Name:SHENANDOAH VALLEY PODIATRY
Entity Type:Organization
Organization Name:SHENANDOAH VALLEY PODIATRY
Other - Org Name:SHENANDOAH VALLEY PODIATRY ASSOCIATES, LTD.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:540-904-1458
Mailing Address - Street 1:60 SUMMERFIELD CT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-4579
Mailing Address - Country:US
Mailing Address - Phone:540-904-1458
Mailing Address - Fax:855-495-0994
Practice Address - Street 1:60 SUMMERFIELD CT
Practice Address - Street 2:SUITE 102
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-4579
Practice Address - Country:US
Practice Address - Phone:540-904-1458
Practice Address - Fax:855-495-0994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300725213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA480032174OtherRAILROAD MEDICARE
VA9304291Medicaid
VA4244980001Medicare NSC
VA9304291Medicaid