Provider Demographics
NPI:1710158373
Name:GREG SHIVERS
Entity Type:Organization
Organization Name:GREG SHIVERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-435-0997
Mailing Address - Street 1:180 NUNN LN
Mailing Address - Street 2:
Mailing Address - City:WHITE STONE
Mailing Address - State:VA
Mailing Address - Zip Code:22578-2208
Mailing Address - Country:US
Mailing Address - Phone:804-435-0997
Mailing Address - Fax:
Practice Address - Street 1:101 HARRIS DRIVE
Practice Address - Street 2:
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482
Practice Address - Country:US
Practice Address - Phone:804-435-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08877Medicare PIN