Provider Demographics
NPI:1821065004
Name:CHILLAG, SHAWN ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:ALEXANDER
Last Name:CHILLAG
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 FL 4
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1227
Mailing Address - Country:US
Mailing Address - Phone:304-388-5590
Mailing Address - Fax:304-388-8238
Practice Address - Street 1:3200 MACCORKLE AVE SE FL 4
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-5590
Practice Address - Fax:304-388-8238
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11208207R00000X
WV9861207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAT3879Medicaid
B42528Medicare UPIN
SCB425287004Medicare PIN
SCB425282603Medicare PIN
SCB425282603Medicare PIN
B42528Medicare UPIN