Provider Demographics
NPI:1265176101
Name:SHALOM GP MEDICAL GROUP LLC
Entity type:Organization
Organization Name:SHALOM GP MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NKECHINYERE
Authorized Official - Middle Name:
Authorized Official - Last Name:UDENYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-334-4171
Mailing Address - Street 1:500 E WHITESTONE BLVD UNIT 3963
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78630-4461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 C-BAR RANCH TRAIL #89
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613
Practice Address - Country:US
Practice Address - Phone:510-334-4171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty