Provider Demographics
NPI:1669529970
Name:SHIPMAN, KALUB GERRARD SR
Entity type:Individual
Prefix:MR
First Name:KALUB
Middle Name:GERRARD
Last Name:SHIPMAN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-3854
Mailing Address - Country:US
Mailing Address - Phone:336-327-7976
Mailing Address - Fax:336-271-2155
Practice Address - Street 1:1719 BRISTOL RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-3854
Practice Address - Country:US
Practice Address - Phone:336-327-7976
Practice Address - Fax:336-271-2155
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC1786374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409116Medicaid
NC6600648Medicaid