Provider Demographics
NPI:1356451702
Name:SHREVES, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHREVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 J D ANDERSON DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3494
Mailing Address - Country:US
Mailing Address - Phone:304-598-1460
Mailing Address - Fax:
Practice Address - Street 1:140 MIDDLETOWN LOOP
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8701
Practice Address - Country:US
Practice Address - Phone:304-333-1150
Practice Address - Fax:304-333-1169
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17953207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0046512000Medicaid
SH7245601Medicare ID - Type Unspecified
WV0046512000Medicaid