Provider Demographics
NPI:1669477196
Name:SHADDUCK, RICHARD KINGSLEY (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:KINGSLEY
Last Name:SHADDUCK
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 1:4815 LIBERTY AVE
Mailing Address - Street 2:STE GR70
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2156
Mailing Address - Country:US
Mailing Address - Phone:412-578-4484
Mailing Address - Fax:412-578-3536
Practice Address - Street 1:4815 LIBERTY AVE
Practice Address - Street 2:STE GR70
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2156
Practice Address - Country:US
Practice Address - Phone:412-578-4484
Practice Address - Fax:412-578-3536
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD011166E207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B33304Medicare UPIN