Provider Demographics
NPI:1083706121
Name:SHENANDOAH EMERGENCY MEDICINE SPECIALISTS LLC
Entity Type:Organization
Organization Name:SHENANDOAH EMERGENCY MEDICINE SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-332-4423
Mailing Address - Street 1:PO BOX 11107
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-1107
Mailing Address - Country:US
Mailing Address - Phone:888-311-8760
Mailing Address - Fax:386-274-7819
Practice Address - Street 1:78 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-1000
Practice Address - Country:US
Practice Address - Phone:540-332-4423
Practice Address - Fax:540-332-5658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10022Medicare PIN
VADF6526Medicare PIN
VA=========OtherCHAMPUS/TRICARE