Provider Demographics
NPI:1689610651
Name:SHOULDIS, ERIC D (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:D
Last Name:SHOULDIS
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 1:3200 MACCORKLE AVE SE
Mailing Address - Street 2:STE B16
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1227
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:3200 MACCORKLE AVENUE SE
Practice Address - Street 2:HOSPITALIST PROGRAM
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-5848
Practice Address - Fax:304-388-9654
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21144208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2402475Medicaid
WV1809361000Medicaid
KY64089113Medicaid
P00045010OtherRAILROAD MEDICARE
SH7369551Medicare PIN
WVSH4107521Medicare ID - Type Unspecified
P00045010OtherRAILROAD MEDICARE
OH2402475Medicaid
SH4107523Medicare PIN