Provider Demographics
NPI:1487639878
Name:SHAHADY, GERTRUDE K (MD)
Entity Type:Individual
Prefix:
First Name:GERTRUDE
Middle Name:K
Last Name:SHAHADY
Suffix:
Gender:F
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 69
Mailing Address - Street 2:
Mailing Address - City:RUSTBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24588-0069
Mailing Address - Country:US
Mailing Address - Phone:434-332-7367
Mailing Address - Fax:434-332-1757
Practice Address - Street 1:925 VILLAGE HWY
Practice Address - Street 2:
Practice Address - City:RUSTBURG
Practice Address - State:VA
Practice Address - Zip Code:24588-4591
Practice Address - Country:US
Practice Address - Phone:434-332-7367
Practice Address - Fax:434-332-1757
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101229867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005644526Medicaid
460635OtherANTHEM
VA080186503OtherMEDICARE RAILROAD
VA0907130004OtherDME RUSTBURG
VA1487639878Medicaid
VA080186503OtherMEDICARE RAILROAD
VA1487639878Medicaid