Provider Demographics
NPI:1518089366
Name:SHENANDOAH PREVENTIVE MEDICINE, INC.
Entity Type:Organization
Organization Name:SHENANDOAH PREVENTIVE MEDICINE, INC.
Other - Org Name:J.A. BURGESS V, D.O.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:V
Authorized Official - Credentials:DO
Authorized Official - Phone:304-263-3335
Mailing Address - Street 1:215 S LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2037
Mailing Address - Country:US
Mailing Address - Phone:304-263-3335
Mailing Address - Fax:304-267-5557
Practice Address - Street 1:215 S LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2037
Practice Address - Country:US
Practice Address - Phone:304-263-3335
Practice Address - Fax:304-267-5557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1000204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVE05965Medicare UPIN