Provider Demographics
NPI:1063454049
Name:SHUGOLL, RICHARD ALAN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:SHUGOLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10650 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8538
Practice Address - Country:US
Practice Address - Phone:704-667-3840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400353207R00000X, 207RI0011X, 207RC0000X, 207RI0011X
SC15172207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8976002Medicaid
SCN00353Medicaid
NCP00612328OtherRAILROAD MEDICARE
NC1063454049Medicaid
NC76002OtherBCBS
NC2197746EMedicare PIN
NCP00612328OtherRAILROAD MEDICARE
SCN00353Medicaid
NCF61190Medicare UPIN
NC8976002Medicaid
NCNC1050CMedicare PIN
SCF611908186Medicare PIN
NC76002OtherBCBS
NC1063454049Medicaid
NC2197746AMedicare PIN
NC2197746Medicare PIN