Provider Demographics
NPI:1578502142
Name:SHIVERS, GREGG ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:ALLEN
Last Name:SHIVERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:
Practice Address - Street 1:1000 OLD DENBIGH BLVD STE 1020A
Practice Address - Street 2:RIVERSIDE LIFELONG HEALTH & AGING SERVICES
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-2017
Practice Address - Country:US
Practice Address - Phone:757-875-2009
Practice Address - Fax:757-369-1042
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1578502142Medicaid
VA021958R53Medicare PIN
VAP00783862Medicare PIN
VA1578502142Medicaid