Provider Demographics
NPI:1326482126
Name:SHADY GROVE ANESTHESIA ASSOCIATE LLC
Entity Type:Organization
Organization Name:SHADY GROVE ANESTHESIA ASSOCIATE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-545-1407
Mailing Address - Street 1:9600 BLACKWELL RD STE 500
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3783
Mailing Address - Country:US
Mailing Address - Phone:301-340-1188
Mailing Address - Fax:301-340-1612
Practice Address - Street 1:9600 BLACKWELL ROAD
Practice Address - Street 2:SUITE 500
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6478
Practice Address - Country:US
Practice Address - Phone:301-340-1188
Practice Address - Fax:301-340-1612
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHADY GROVE FERTILITY RSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-23
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR115576367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty