Provider Demographics
NPI:1114437647
Name:SHAW, RODNEY (SCCM)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:SCCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 BARRINGTON HILL CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1876
Mailing Address - Country:US
Mailing Address - Phone:804-503-6087
Mailing Address - Fax:757-366-0709
Practice Address - Street 1:1401 KEMPSVILLE RD STE D
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-8316
Practice Address - Country:US
Practice Address - Phone:757-366-0708
Practice Address - Fax:757-366-0709
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1619399748Medicaid