Provider Demographics
NPI:1639268352
Name:SHIVERS, RICHARD MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MARK
Last Name:SHIVERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9471 MARKET ST
Mailing Address - Street 2:STE B
Mailing Address - City:NORTH LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:44452-8702
Mailing Address - Country:US
Mailing Address - Phone:330-729-2388
Mailing Address - Fax:330-629-6468
Practice Address - Street 1:564 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-2914
Practice Address - Country:US
Practice Address - Phone:234-567-8150
Practice Address - Fax:234-567-8189
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-065781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0975995Medicaid
OHP01712254OtherRR MEDICARE
OHP01712254OtherRR MEDICARE
OHSH0763412Medicare ID - Type Unspecified