Provider Demographics
NPI:1164979787
Name:SHEVARDNADZE, ARTHUR
Entity Type:Individual
Prefix:
First Name:ARTHUR
Middle Name:
Last Name:SHEVARDNADZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-2431
Mailing Address - Country:US
Mailing Address - Phone:973-635-2800
Mailing Address - Fax:973-635-9392
Practice Address - Street 1:40 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NJ
Practice Address - Zip Code:07928-2431
Practice Address - Country:US
Practice Address - Phone:973-635-2800
Practice Address - Fax:973-635-9392
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01689200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ043171Medicare PIN