Provider Demographics
NPI:1720118680
Name:SHENANDOAH MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SHENANDOAH MEMORIAL HOSPITAL
Other - Org Name:SHENANDOAH MEMORIAL WOUND CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:NEVADA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-536-0103
Mailing Address - Street 1:759 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22664-1127
Mailing Address - Country:US
Mailing Address - Phone:540-459-1100
Mailing Address - Fax:540-459-1293
Practice Address - Street 1:759 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1127
Practice Address - Country:US
Practice Address - Phone:540-459-1100
Practice Address - Fax:540-459-1293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00424037OtherMEDICARE RAILROAD
CK0882OtherMEDICARE RAILROAD
VAC00248Medicare PIN