Healthcare Provider Details

I. General information

NPI: 1497333520
Provider Name (Legal Business Name): AVERY BLAKE SHRUM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 HINDMAN BYP
HINDMAN KY
41822-8666
US

IV. Provider business mailing address

PO BOX 1988
HAZARD KY
41702-1988
US

V. Phone/Fax

Practice location:
  • Phone: 606-439-1300
  • Fax: 606-439-1400
Mailing address:
  • Phone: 606-435-7642
  • Fax: 606-436-5282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05838
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: