Healthcare Provider Details

I. General information

NPI: 1073099750
Provider Name (Legal Business Name): SHANE MUDRINICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRIAN D ALLGOOD ARMY COMMUNITY HOSPITAL (BDAACH) UNIT #15245; BLDG 3031
APO AP
96271
US

IV. Provider business mailing address

8901 ROCKVILLE PIKE
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-1155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101276111
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: