Provider Demographics
NPI:1801182332
Name:SHIVELY, NATHAN R (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:R
Last Name:SHIVELY
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 1:420 E NORTH AVE STE 406
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4746
Mailing Address - Country:US
Mailing Address - Phone:412-359-3683
Mailing Address - Fax:412-359-3373
Practice Address - Street 1:320 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4756
Practice Address - Country:US
Practice Address - Phone:412-359-3683
Practice Address - Fax:412-359-3373
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD461187207RI0200X
MEMD20188207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103312283Medicaid