Healthcare Provider Details

I. General information

NPI: 1912235268
Provider Name (Legal Business Name): SHANAHAN RHEUMATOLOGY AND IMMUNOTHERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2009
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10208 CERNY STREET WAKE MED BRIER CREEK MEDICAL PARK
RALEIGH NC
27617
US

IV. Provider business mailing address

10208 CERNY STREET WAKE MED BRIER CREEK MEDICAL PARK
RALEIGH NC
27617
US

V. Phone/Fax

Practice location:
  • Phone: 919-949-2228
  • Fax:
Mailing address:
  • Phone: 919-949-2228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number9801767
License Number StateNC

VIII. Authorized Official

Name: MISS NICOLE COUTURE
Title or Position: BILLING AGENT
Credential:
Phone: 413-772-8500